CHADS, SHMADS: What’s All This About Anticoagulation? COPYRIGHT © 2016, ALL RIGHTS RESERVED From the Publishers of

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Consult Guys: I need your help to make a clinical decision regarding a clinical problem. I just evaluated a 60-year-old woman who has asymptomatic atrial fibrillation. I discovered the atrial fibrillation during a recent visit. Continuous cardiac monitoring documented that the atrial fib was persistent and that the ventricular response was well controlled. She has no symptoms. She has no history of heart failure, hypertension, diabetes, or prior stroke. An echocardiogram reveals that her heart is structurally normal. Her exam is unremarkable except for atrial fib. Her laboratory studies are normal. My question relates as to whether or not to begin antithrombotic or anticoagulant therapy. Her CHADS2-VASC score is 1 and current guidelines are unclear as to what to do. Consult Guys: I need your help to make a clinical decision regarding a clinical problem. I just evaluated a 60-year-old woman who has asymptomatic atrial fibrillation. I discovered the atrial fibrillation during a recent visit. Continuous cardiac monitoring documented that the atrial fib was persistent and that the ventricular response was well controlled. She has no symptoms. She has no history of heart failure, hypertension, diabetes, or prior stroke. An echocardiogram reveals that her heart is structurally normal. Her exam is unremarkable except for atrial fib. Her laboratory studies are normal. My question relates as to whether or not to begin antithrombotic or anticoagulant therapy. Her CHADS2-VASC score is 1 and current guidelines are unclear as to what to do. Copyright © 2016

Atrial Fibrillation million Americans Copyright © 2016

Atrial Fibrillation million Americans Copyright © 2016

*January CT, Wann L, Alpert JS, et al AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1-e76. doi: /j.jacc

Key Points from the 2014 Guideline Antithrombotic rx: individualize- benefit vs risk and patient preference Antithrombotic therapy regardless of whether AF pattern is permanent, persistent, or episodic Non-valvular AF embolic risk: CHA2DS2-VASc Mechanical heart valve + AF = warfarin Non-valvular AF indications for oral anticoagulation are:  Prior stroke  Prior TIA  CHA2DS2-VASc > 2 Copyright © 2016

CHADS2 Score Congestive heart failure - 1pt Hypertension - 1pt Age > pt Diabetes - 1pt Stroke or TIA - 2 pts 0 points – low risk 1-2 points – moderate risk > 3 points – high risk *Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA Jun (22):

CHA 2 DS 2 - VAS c Congestive heart failure/ LV dysfunction - 1pt Hypertension - 1pt Age > pt Diabetes - 1pt Stroke or TIA - 2 pts Vascular disease (prior MI, PAD, aortic plaque) - 1pt Age pt Sex category (ie female gender) - 1pt *Lip GY, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41(12):

Anticoagulation Who do we anticoagulate? CHA 2 DS 2 - VAS c > 2 Afib + prior stroke or TIA Afib + mechanical valve: warfarin Valvular afib Who do we NOT anticoagulate? CHA 2 DS 2 - VAS c = 0 Copyright © 2016

CHA 2 DS 2 -VASC = 1  No antithrombotic therapy  Oral anticoagulant  Aspirin Copyright © 2016

*Camm AJ et al focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J.2012 Nov;33(21): doi: /eurheartj/ehs253. Epub 2012 Aug 24. Women whose CHA2DS2VASc = 1 Need not be treated with antithrombotics

Female gender, age < 65 not a risk factor for stroke *Olesen J, Fauchier L, Lane DA, Taillandier S, Lip GH. Risk factors for stroke and thromboembolism in relation to age among patients with atrial fibrillation. Chest. 2012;141(1): doi: /chest

Our Patient 60-year-old woman  No antithrombotic  No anticoagulant  Follow for development of other embolic risk factors Copyright © 2016

SPAF I Study Aspirin (325mg) reduced stroke risk approximately 20% Major bleed incidence on aspirin 0.5% Our patient % embolic risk  20% risk reduction with aspirin = % embolic risk  0.5% risk major bleed

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