1. Anticoagulation in Atrial Fibrillation
Jesse Tran R2

5. Class I recommendations
In patients with nonvalvular AF, calculate CHA2DS2-VASc
CHA2DS2-VASc of 2 or greater, oral anticoagulation recommended.
Wafarin with INR 2-3, dabigatran, rivaroxaban, or apixaban.
In patients with A flutter, anticoagulation is recommended as above.

6. Class IIa, IIb
In patient with nonvalvular AF and CHA2DS2-VASc of 0, no need for anticoagulation.
CHA2DS2-VASc of 1, can consider anticoagulation or ASA.
Patients undergoing PCI, BMS considered to minimize duration of dual anti platelet therapy.
Following coronary revascularization in pts with A fib and a CHA2DS2-VASc of 2 or greater, can use plavix with oral anticoagulants, but without ASA.

7. Class III
Direct thrombin inh and factor Xa inh are not recommended in patents with AF and end-stage CKD or HD. Lack of evidence
Direct thrombin inh, dabigatran, should not be used in pts with AF and mechanical heart valve.

8. Bleeding Risk
HAS-BLED: HTN - sbp >160, Abnormal renal/liver function, Stroke, Bleeding hx or predisposition, Labile INR, Elderly - >65, Drugs/alcohol.
Score of greater than or equal to 3 indicates patients at higher risk of bleeding.

9. Antiplatelet Therapy
ASA has been shown to be beneficial in both primary and secondary prevention of stroke, though inferior to other methods of anticoagulation.
Plavix + ASA vs Warfarin was compared in the ACTIVE-W trial. Ended early due to inferiority between these two groups in pts with CHADS2 = 2.
Plavix + ASA proved to be superior to ASA alone in ACTIVE-A trial.

11. Warfarin Vitamin K antagonist
ARR 2.7% per year, NNT 37 in one year to prevent 1 stroke, NNT of 12 in pts with prior stroke.
Risk of stroke in pts with warfarin 1.66% annually
Risk of intracranial hemorrhage was significantly increased in those with oral anticoagulants.
Numerous drug interactions, affects on diet, need for frequent monitoring.

12. Direct Thrombin Inhibitor
Renally excreted, lower dose approved in pts with CrCl mL/min.
Compared with warfarin in RE-LY trial
Dabigatran at 150mg BID superior to warfarin in this study, 110mg BID non inferior for primary outcomes of stroke and systemic embolism.
Lower rates of intracranial bleeding, but higher rates of GI bleeding in the 150mg BID group.

13. Factor Xa Inhibitor
Single daily dose for reduction of stroke and systemic embolism in patients with nonvalvular AF.
Renal excretion
ROCKET AF trial which showed non inferiority.
Major bleeding was similar between warfarin and rivaroxaban, but had less fatal bleeding and less ICH.

14. Factor Xa Inhibitors Hepatic elimination
ARISTOTLE trial - showed significant reduction in overall stroke, emboli, and major bleeding events.
Fewer ICH with similar GI bleeding complications.

15. Benefits of new anticoagulation agents
Fewer drug-drug interactions
No dietary effects
Less risk of ICH
No need for frequent monitoring
No reversal agents, though short half life

16. Dose Adjustments