Optimize Anticoagulation for Patients With Atrial Fib

You’ll see continued emphasis on optimizing anticoagulants for atrial fib...based on new Am Coll of Cardiology/Am Heart Assn guidelines.

Use these strategies to balance risks and benefits.

Start by identifying stroke risk factors in atrial fib.

For example, the “CHA2DS2-VASc” score includes factors such as stroke, hypertension, female sex, and age 65 and up.

Expect anticoagulation to provide a net benefit for most patients with atrial fib plus at least one non-sex risk factor.

Choose a direct oral anticoagulant (DOAC) over warfarin for most atrial fib patients.

DOACs reduce stroke risk at least as well as warfarin...cause slightly less intracranial bleeding...and don’t require INR monitoring.

All DOACs seem similarly effective for stroke prevention...but there aren’t head-to-head trials. Often lean toward apixaban (Eliquis) if practical. It seems to cause less significant bleeding.

In fact, the Beers Criteria caution about bleeding risk with dabigatran (Pradaxa) or rivaroxaban (Xarelto) in older adults.

Keep in mind, newer data support that DOACs are an option for patients with atrial fib and a bioprosthetic heart valve.

But avoid DOACs with a mechanical heart valve or moderate to severe mitral stenosis...continue to rely on warfarin for these patients.

Generally avoid DOACs with certain meds...such as rifampin or carbamazepine. These lower DOAC levels...and may increase clot risk. Instead, recommend warfarin...with very close monitoring.

Weigh adherence...since missing just a couple DOAC doses may raise clot risk. Warfarin is longer-acting and may be more forgiving.

And consider cost, payer coverage, etc. Most DOACs cost about $500 per month...generic dabigatran about $200...and warfarin about $10 plus routine INR monitoring.

Look for ways to limit bleeding risk...such as adjusting DOAC doses for kidney function, managing high BP, or reevaluating NSAIDs and aspirin.

Don't use aspirin instead of an anticoagulant to reduce stroke risk in atrial fib...even in lower-risk patients. Antiplatelets aren’t as effective...and may not have lower bleeding risk.

See our resource, A-Fib: Focus on Pharmacotherapy, for guidance about rate and rhythm control, stroke risk scores, and more.

Key References

  • Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jan 2;149(1):e1-e156.
  • Lau WCY, Torre CO, Man KKC, et al. Comparative Effectiveness and Safety Between Apixaban, Dabigatran, Edoxaban, and Rivaroxaban Among Patients With Atrial Fibrillation : A Multinational Population-Based Cohort Study. Ann Intern Med. 2022 Nov;175(11):1515-1524.
  • By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023 Jul;71(7):2052-2081.
  • Medication pricing by Elsevier, accessed Jan 2024.
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