Management of Anticoagulation in Patients With Atrial Fibrillation

JAMA, 21 July 2015

This JAMA Clinical Guidelines Synopsis article summarizes the evidence for management of anticoagulation therapy in patients with atrial fibrillation. …

Major recommendations

  • For nonvalvular AF that is paroxysmal, persistent, or permanent, oral anticoagulation is recommended for patients with prior stroke, transient ischemic attack, or a CHA₂DS₂-VASc score of 2 or greater (class I recommendation) using warfarin (level of evidence A) or a direct thrombin or factor Xa inhibitor (level of evidence B). Antithrombotic therapy should be managed the same way for atrial flutter (class I recommendation, level of evidence C). For patients with nonvalvular AF and a CHA₂DS₂-VASc score of 0, it is reasonable to omit antithrombotic therapy (class IIa recommendation, level of evidence B). For a CHA₂DS₂-VASc score of 1, treatment with an oral anticoagulant or aspirin may be considered.
  • In the setting of chronic kidney disease (CKD), warfarin should be used in the setting of a creatinine clearance less than 15 mL/min or hemodialysis (class IIa recommendation, level of evidence B); reduced doses of dabigatran, rivaroxaban, or apixaban may be considered for moderate to severe CKD (class IIb recommendation, level of evidence C). Dabigatran and rivaroxaban should not be used in patients with end-stage CKD (class III recommendation, no benefit).

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