Antithrombotic Therapy for Atrial Fibrillation

Abstract

Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF at high risk of stroke (CHADS(2) score of ≥ 2). At lower levels of stroke risk, antithrombotic treatment decisions will require a more individualized approach.

Preventing bleeding and thromboembolic complications in atrial fibrillation patients undergoing surgery

“…The first main studies accepted higher levels of anticoagulation 27,28,29,30 , but there is a strong consensus nowadays that the risk of bleeding complications increases disproportionally in patients with INR of 4 or more 3,7,8 .…”

“…It should be remembered however that typical preventive regimens for venous thrombosis exhibit minimal or no efficacy against arterial thromboembolism. The manuscript reviews the vitamin K antagonist Warfarin and the new oral anticoagulants [(NOACs): direct thrombin and factor Xa inhibitors] and is partially based in a number of recently published guidelines from American and European medical societies to which the interested reader is directed for more details 2,3,4,5,6,7,8,9,10 .…”

“…Using one of these systems in patients with cryptogenic CI, AF episodes of at least 30 seconds were detected 6 times more frequently than in a control group (8.9% vs. 1.4%) after 6 months (12.4% vs. 2% in 12 months) 23 . A table including AF patients and other risk groups for thromboembolic complications has been developed ( Table 2) 7,8 . It can be used in surgical patients, although it is based on annual risk in clinical settings 7 .…”

“…Triple therapy (double antiaggregant and anticoagulation) is associated with increased mortality and major bleeding risk and no additional reduction of thromboembolic events when compared to single antiaggregation with clopidogrel plus Warfarin treatment 40 . Some medical societies suggest, based in somewhat limited evidence, the concomitant use of Warfarin and ASA or clopidogrel/prasugrel in special situations for 12 months (CHADS2 ≥ 2) or for an undefined time (acute coronary syndromes); and triple therapy for 12 months after pharmacological stent placement 3,7,8,40,41 . In AF anticoagulated patients undergoing angioplasty/stent placement, the antiplatelet drugs should be used in low doses; whenever possible, nonpharmacological stents should be preferred in anticoagulated patients (minimizing time on triple therapy).…”

The role of anticoagulants, antiplatelet agents, and their reversal strategies in the management of intracerebral hemorrhage

“…29,52 Recently, the American College of Chest Physicians published their newest recommendations for antithrombotic therapy for atrial fibrillation; they are now suggesting dabigatran 150 mg twice daily rather than warfarin when oral anticoagulant therapy is recommended. 77 As these newer oral anticoagulants are increasingly prescribed more frequently, we hope a real world decrease in the frequency of anticoagulantrelated ICH will follow. Nevertheless, there will be patients with anticoagulant-related ICH who need emergency attention and immediate reversal of the anticoagulating effects.…”