8
Treatment
Table 4. Risk-Based Antithrombotic Therapy
Recommendations COR LOE
In patients with AF, antithrombotic therapy should be
individualized based on shared decision making after
discussion of the absolute and relative risks of stroke and
bleeding, and the patient's values and preferences.
I C
Selection of antithrombotic therapy should be based on the
risk of thromboembolism irrespective of whether the AF
pattern is paroxysmal, persistent, or permanent.
I B
In patients with nonvalvular AF, the CHA
2
DS
2
-VASc score
is recommended for assessment of stroke risk.
I B
For patients with AF who have mechanical heart valves,
warfarin is recommended, and the target INR intensity
(2.0-3.0 or 2.5-3.5) should be based on the type and
location of the prosthesis.
I B
For patients with nonvalvular AF with prior stroke, TIA,
or a CHA
2
DS
2
-VASc score ≥2, oral anticoagulants are recommended.
Options include:
• Warfarin (INR 2.0-3.0)
I A
• Dabigatran, rivaroxaban, or apixaban.
I B
Among patients treated with warfarin, the INR should
be determined at least weekly during initiation of
antithrombotic therapy and at least monthly when
anticoagulation (INR in range) is stable.
I A
For patients with nonvalvular AF unable to maintain
a therapeutic INR level with warfarin, use of a direct
thrombin or factor Xa inhibitor (dabigatran, rivaroxaban,
or apixaban) is recommended.
I C
Re-evaluation of the need for and choice of antithrombotic
therapy at periodic intervals is recommended to reassess
stroke and bleeding risks.
I C
Bridging therapy with UFH or LMWH is recommended
for patients with AF and a mechanical heart valve
undergoing procedures that require interruption of
warfarin. Decisions regarding bridging therapy should
balance the risks of stroke and bleeding.
I C
For patients with AF without mechanical heart valves who
require interruption of warfarin or new anticoagulants for
procedures, decisions about bridging therapy (LMWH or
UFH) should balance the risks of stroke and bleeding and
the duration of time a patient will not be anticoagulated.
I C
Renal function should be evaluated before initiation of
direct thrombin or factor Xa inhibitors and should be re-
evaluated when clinically indicated and at least annually.
I B
