1. Risk With Atrial Fibrillation: A Guy Thing?
From the Publishers of
Consult Guys
Risk With Atrial Fibrillation: A Guy Thing?
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3. Consult Guys:
I need your help to make a clinical decision regarding a clinical problem.
I watched with rapt attention one of your recent shows answering a fan’s question about a 60- year-old woman with asymptomatic atrial fibrillation. She had no symptoms and no history of heart failure, hypertension, diabetes, or prior stroke. An echocardiogram revealed that her heart is structurally normal.
Her exam was unremarkable except for afib.
Her laboratory studies were normal.
You pointed out that the 2014 ACC AHA atrial fibrillation guideline recommends no antithrombotic therapy for patients with CHA2DS2-VASc score 0, and definite anticoagulant therapy for those with CHA2DS2-VASc score > 2.
You used recommendations from the European Society of Cardiology to support no anticoagulation for women whose only CHA2DS2-VASc risk factor is their gender.
Well I need your astute insight to guide me in the care of a 68 year old male who has afib. His CHA2DS2-VASc score is 1 and that is a result of his age.
The ACC/AHA Guideline is really vague for the patient CHA2DS2-VASc score of 1 and gives me a full range of options regarding thromboembolic risk reduction ranging from doing nothing to using anticoagulation.
Is there any way that you guys can bring some clarity to this?

4. Key Points from the 2014 ACC-AHA Guideline
Antithrombotic rx: individualize- benefit, risk, patient preference
Antithrombotic therapy regardless of whether AF pattern is permanent, persistent, episodic
Nonvalvular AF embolic risk: CHA2DS2-VASc
Mechanical heart valve + AF = warfarin
Nonvalvular AF Oral anticoagulants
Prior stroke
Prior TIA
CHA2DS2-VASc > 2
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

5. How do we determine stroke risk ?
CHA2DS2-VASc
Congestive heart failure/ LV dysf - 1pt
Hypertension - 1pt
Age > pt
Diabetes - 1pt
Stroke or TIA pts
Vascular disease (prior MI, PAD, aortic plaque) - 1pt
Age pt
Sex category (ie female gender) - 1pt
Reproduced with permission from the American College of Chest Physicians
Lip GH, Nieuwlaat R, Pisters R, Lane DA, Crijns HM. Refining clinical risk stratification for predicting stroke and thromboembolism
in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137(2):

6. Who do we anticoagulate?
CHA2DS2-VASc > 2
Atrial Fibrillation + prior stroke or TIA
Atrial Fibrillation + mechanical valve
Valvular Atrial Fibrillation
Mitral stenosis
Mechanical heart valve
Copyright © 2016

7. CHA2DS2 VASc = 1
Women whose CHA2DS2VASc = 1 need not be treated with antithrombotics
Camm AJ, et al focused update of the ESC Guideline s 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; 21: doi: /eurheartj/ehs253. Epub 2012 Aug 24.

8. Male CHA2DS2-VASc = 1 CHA2DS2-VASc = 1 No antithrombotic therapy
Oral anticoagulant
Aspirin
Copyright © 2016

9. CHA2DS2-VASc = 1
Friberg L, et al. Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1.
J Am Coll Cardiol. 2015; 653: doi: /j.jacc

10. CHA2DS2-VASc = 1
Friberg L, et al. Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1.
J Am Coll Cardiol. 2015; 653: doi: /j.jacc

12. CHA2DS2-VASc = 1
Chao T, Liu C, Wang K, et al. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?. J Am Coll Cardiol. 2015;65: doi: /j.jacc

13. Male CHA2DS2 VASc = 1
Reprinted from J Am Coll Cardiol, 65, Chao T, Liu C, Wang K, et al., Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?, , Copyright 2015, with permission from Elsevier .
Chao T, Liu C, Wang K, et al. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score
(Beyond Sex) Receive Oral Anticoagulation?. J Am Coll Cardiol. 2015;65: doi: /j.jacc

14. Female CHA2DS2-VASc =2
Reprinted from J Am Coll Cardiol, 65, Chao T, Liu C, Wang K, et al., Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?, , Copyright 2015, with permission from Elsevier .
Chao T, Liu C, Wang K, et al. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score
(Beyond Sex) Receive Oral Anticoagulation?. J Am Coll Cardiol. 2015;65: doi: /j.jacc

15. CHA2DS2-VASc = 1 men, 2 women European Society of Cardiology 2012
Warfarin
DOAC
If refuses oral anticoagulant:
ASA + Clopidogrel
Bleeding risk similar to OAC
ASA alone may be ineffective

16. SPAF I-III trials ASA, warfarin, no rx
Disabling strokes are cardioembolic
Most ischemic strokes in AF are cardioembolic
Warfarin reduces cardioembolic stroke by 83%
Aspirin reduces overall stroke by 20%
Aspirin minimal reduction in disabling stroke
Hart R, G, Pearce L, A, Miller V, T, Anderson D, C, Rothrock J, F, Albers G, W, Nasco E, Cardioembolic vs. Noncardioembolic Strokes in Atrial Fibrillation: Frequency and Effect of Antithrombotic Agents in the Stroke Prevention in Atrial Fibrillation Studies. Cerebrovasc Dis 2000;10:39-43.

17. Swedish National Registry 2005-2009 ASA: 58,671 No ASA: 56,514
Själander S, et al. Atrial fibrillation patients do not benefit from acetylsalicylic acid. Europace May 2014; 16: DOI: /europace/eut333
Swedish National Registry
ASA: 58,671
No ASA: 56,514

18. Ischemic stroke No Aspirin Aspirin
Reproduced with permission from European Society of Cardiology
Själander S, et al. Atrial fibrillation patients do not benefit from acetylsalicylic acid. Europace May 2014; 16: DOI: /europace/eut333

19. Male CHA2DS2-VASc = 1
Reprinted from J Am Coll Cardiol, 65, Chao T, Liu C, Wang K, et al., Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?, , Copyright 2015, with permission from Elsevier .
Chao T, Liu C, Wang K, et al. Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score
(Beyond Sex) Receive Oral Anticoagulation?. J Am Coll Cardiol. 2015;65: doi: /j.jacc

20. Our patient 68-year-old man CHA2DS2-VASc = 1 (age)
Hazard ratio for stroke = 3
Warfarin or DOAC
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