Is an Oral Anticoagulant Necessary for Young Atrial Fibrillation Patients With a CHA ₂ DS ₂ ‐VASc Score of 1 (Men) or 2 (Women)?

Abstract

BackgroundRecent studies demonstrated that oral anticoagulants (OACs) should be considered for patients with atrial fibrillation and 1 risk factor in addition to sex. Because age is an important determinant of ischemic stroke, the strategy for stroke prevention may be different for these patients in different age strata. The aim of this study was to investigate whether OACs should be considered for patients aged 20 to 49 years with atrial fibrillation and a CHA2DS2‐VASc score of 1 (men) or 2 (women).Methods and ResultsUsing the Taiwan National Health Insurance Research Database, 7374 male patients with atrial fibrillation and a CHA2DS2‐VASc score of 1 and 4461 female patients with atrial fibrillation and a CHA2DS2‐VASc score of 2 and all without antithrombotic therapies were identified and stratified into 3 groups by age. The threshold for the initiation of OACs for stroke prevention was set at a stroke rate of 1.7% per year for warfarin and 0.9% per year for non–vitamin K antagonist OACs. Among male patients aged 20 to 49 years with a CHA2DS2‐VASc score of 1, the risk of ischemic stroke was 1.30% per year and ranged from 0.94% per year for those with hypertension to 1.71% for those with congestive heart failure. Among female patients aged 20 to 49 years with a CHA2DS2‐VASc score of 2, the risk of ischemic stroke was 1.40% per year and ranged from 1.11% per year for those with hypertension to 1.67% for those with congestive heart failure.ConclusionsFor atrial fibrillation patients aged 20 to 49 years with 1 risk factor in addition to sex, non–vitamin K antagonist OACs should be considered for stroke prevention to minimize the risk of a potentially fatal or disabling event.

2018 ESC/ESH Guidelines for the management of arterial hypertension

“…Detailed information on hypertension and oral anticoagulants has been published recently [526,536]. Anticoagulants should be used to reduce the risk of stroke in most AF patients with hypertension, including those with AF in whom hypertension is the single additional stroke risk factor [554,555]. BP control is important to minimize the risks of AF-related stroke and oral anticoagulant-related bleeding.…”

Stroke prevention in atrial fibrillation: Past, present and future

“…Even a single stroke risk factor confers an accentuated risk of stroke and mortality, and the net clinical benefit (NCB) balancing stroke reduction against serious bleeding with OAC use is clearly positive in such patients, compared to aspirin or no treatment (22)(23)(24). In contrast, aspirin has a neutral or negative NCB, indicating no advantage even in patients with a CHA 2 DS 2 -VASc score of 1 (or 2 in females) (25).…”

Stroke Prevention in Atrial Fibrillation: Focus on Asian Patients

“… 1) Indeed, considering the evidence supporting NCB, patients with a CHA 2 DS 2 -VASc score of 1 in males or 2 in females should receive OAC, as is recommended by guidelines. 23) 24) 25) 26) 35) 36) …”

“… 31) 37) In another study from Taiwan, in patients with AF aged 20 to 49 and with a CHA 2 DS 2 -VASc score of 1 in males, the risk of ischemic stroke was 1.30% (0.94-1.71%) per year; which among those with a CHA 2 DS 2 -VASc score of 2 in females, this risk was 1.40% (1.11–1.67%). 36) For these patients, may be NOAC should be considered for stroke prevention considering the treatment threshold of obtaining a positive NCB at a 0.9% annual risk of stroke.…”