| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Guest Access | Sign In via User Name/Password
|
|
|
|||||||
Guest Access | Sign In via User Name/Password |
|||||||||
Correspondence to: Daniel E. Singer, MD, Clinical Epidemiology Unit, S50-9, Massachusetts General Hospital, Boston, MA 02114; e-mail: dsinger{at}partners.org
This chapter about antithrombotic therapy in atrial fibrillation (AF) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients’ values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S). Among the key recommendations in this chapter are the following (all vitamin K antagonist [VKA] recommendations have a target international normalized ratio [INR] of 2.5; range, 2.0 to 3.0): In patients with persistent or paroxysmal AF (PAF) [intermittent AF] at high risk of stroke (ie, having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age > 75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus), we recommend anticoagulation with an oral VKA, such as warfarin (Grade 1A). In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk factors, we recommend antithrombotic therapy with either an oral VKA or aspirin, 325 mg/d, in this group of patients who are at intermediate risk of stroke (Grade 1A). In patients with persistent AF or PAF < 65 years old and with no other risk factors, we recommend aspirin, 325 mg/d (Grade 1B). For patients with AF and mitral stenosis, we recommend anticoagulation with an oral VKA (Grade 1C+). For patients with AF and prosthetic heart valves, we recommend anticoagulation with an oral VKA (Grade 1C+); the target INR may be increased and aspirin added depending on valve type and position, and on patient factors. For patients with AF of 
48 h or of unknown duration for whom pharmacologic or electrical cardioversion is planned, we recommend anticoagulation with an oral VKA for 3 weeks before and for at least 4 weeks after successful cardioversion (Grade 1C+). For patients with AF of 48 h or of unknown duration undergoing pharmacologic or electrical cardioversion, an alternative strategy is anticoagulation and screening multiplane transesophageal echocardiography (Grade 1B). If no thrombus is seen and cardioversion is successful, we recommend anticoagulation for at least 4 weeks (Grade 1B). For patients with AF of known duration < 48 h, we suggest cardioversion without anticoagulation (Grade 2C). However, in patients without contraindications to anticoagulation, we suggest beginning IV heparin or low molecular weight heparin at presentation (Grade 2C).
Key Words: antithrombotic • atrial fibrillation • mitral stenosis • prophylaxis • stroke
This article has been cited by other articles:
|
|
 |
|
  Stroke Risk in Atrial Fibrillation Working Group Comparison of 12 Risk Stratification Schemes to Predict Stroke in Patients With Nonvalvular Atrial Fibrillation Stroke, June 1, 2008; 39(6): 1901 - 1910. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Baruch, B. F. Gage, J. Horrow, S. Juul-Moller, A. Labovitz, M. Persson, and M. Zabalgoitia Can Patients at Elevated Risk of Stroke Treated With Anticoagulants Be Further Risk Stratified? Stroke, September 1, 2007; 38(9): 2459 - 2463. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Hirsh, M. O'Donnell, and J. W. Eikelboom Beyond Unfractionated Heparin and Warfarin: Current and Future Advances Circulation, July 31, 2007; 116(5): 552 - 560. [Full Text] [PDF]
|
|
|
|
|
|
D. G. Sherman Stroke Prevention in Atrial Fibrillation: Pharmacological Rate Versus Rhythm Control Stroke, February 1, 2007; 38(2): 615 - 617. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Dentali, J. D. Douketis, W. Lim, and M. Crowther Combined Aspirin-Oral Anticoagulant Therapy Compared With Oral Anticoagulant Therapy Alone Among Patients at Risk for Cardiovascular Disease: A Meta-analysis of Randomized Trials Arch Intern Med, January 22, 2007; 167(2): 117 - 124. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. J. O'Donnell, N. Valens, M. G. Lansberg, and C. A.C. Wijman Thyroid replacement therapy and atrial fibrillation in acute ischemic stroke. Neurology, November 14, 2006; 67(9): 1714 - 1715. [Full Text] [PDF]
|
|
|
|
 |
|
 C. A. Thompson Cardiology groups' antithrombotic guidelines challenge ACCP's. Am. J. Health Syst. Pharm., September 15, 2006; 63(18): 1676 - 1677. [Full Text] [PDF]
|
|
|
|
 |
|
 M. Gomberg-Maitland, N. K. Wenger, J. Feyzi, M. Lengyel, A. S. Volgman, P. Petersen, L. Frison, and J. L. Halperin Anticoagulation in women with non-valvular atrial fibrillation in the stroke prevention using an oral thrombin inhibitor (SPORTIF) trials Eur. Heart J., August 2, 2006; 27(16): 1947 - 1953. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. J. Marder, D. J. Chute, S. Starkman, A. M. Abolian, C. Kidwell, D. Liebeskind, B. Ovbiagele, F. Vinuela, G. Duckwiler, R. Jahan, et al. Analysis of Thrombi Retrieved From Cerebral Arteries of Patients With Acute Ischemic Stroke Stroke, August 1, 2006; 37(8): 2086 - 2093. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Lakshminarayan, C. A. Solid, A. J. Collins, D. C. Anderson, and C. A. Herzog Atrial Fibrillation and Stroke in the General Medicare Population: A 10-Year Perspective (1992 to 2002) Stroke, August 1, 2006; 37(8): 1969 - 1974. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein, R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, T. J. DeGraba, P. B. Gorelick, J. R. Guyton, et al. Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Stroke, June 1, 2006; 37(6): 1583 - 1633. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. D. Douketis, K. Arneklev, S. Z. Goldhaber, J. Spandorfer, F. Halperin, and J. Horrow Comparison of Bleeding in Patients With Nonvalvular Atrial Fibrillation Treated With Ximelagatran or Warfarin: Assessment of Incidence, Case-Fatality Rate, Time Course and Sites of Bleeding, and Risk Factors for Bleeding. Arch Intern Med, April 24, 2006; 166(8): 853 - 859. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Perez-Gomez, A. Salvador, J. Zumalde, J. A. Iriarte, J. Berjon, E. Alegria, C. Almeria, R. Bover, D. Herrera, C. Fernandez, et al. Effect of antithrombotic therapy in patients with mitral stenosis and atrial fibrillation: a sub-analysis of NASPEAF randomized trial Eur. Heart J., April 2, 2006; 27(8): 960 - 967. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. M. Hylek, J. D'Antonio, C. Evans-Molina, C. Shea, L. E. Henault, and S. Regan Translating the Results of Randomized Trials into Clinical Practice: The Challenge of Warfarin Candidacy Among Hospitalized Elderly Patients With Atrial Fibrillation Stroke, April 1, 2006; 37(4): 1075 - 1080. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G Y H Lip and C J Boos Antithrombotic treatment in atrial fibrillation Heart, February 1, 2006; 92(2): 155 - 161. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Kaul, G. A. Diamond, and W. S. Weintraub Trials and Tribulations of Non-Inferiority: The Ximelagatran Experience J. Am. Coll. Cardiol., December 6, 2005; 46(11): 1986 - 1995. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. J McGriff-Lee, G. Csako, J. T Chen, D. K Dang, K. G Rosenfeld, R. O Cannon, L R. Macklin, R. A Wesley, and Anticoagulation Working Group Search for Predictors of Nontherapeutic INR Results with Warfarin Therapy Ann. Pharmacother., December 1, 2005; 39(12): 1996 - 2002. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
U. Stenestrand, J. Lindback, L. Wallentin, and for the RIKS-HIA Registry Anticoagulation Therapy in Atrial Fibrillation in Combination With Acute Myocardial Infarction Influences Long-Term Outcome: A Prospective Cohort Study From the Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA) Circulation, November 22, 2005; 112(21): 3225 - 3231. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Nieuwlaat, A. Capucci, A. J. Camm, S. B. Olsson, D. Andresen, D. W. Davies, S. Cobbe, G. Breithardt, J.-Y. Le Heuzey, M. H. Prins, et al. Atrial fibrillation management: a prospective survey in ESC Member Countries: The Euro Heart Survey on Atrial Fibrillation Eur. Heart J., November 2, 2005; 26(22): 2422 - 2434. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. A. Wilke, R. L. Berg, H. J. Vidaillet, M. D. Caldwell, J. K. Burmester, and M. A. Hillman Impact of Age, CYP2C9 Genotype and Concomitant Medication on the Rate of Rise for Prothrombin Time During the First 30 Days of Warfarin Therapy Clin. Med. Res., November 1, 2005; 3(4): 207 - 213. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. C. Fang, D. E. Singer, Y. Chang, E. M. Hylek, L. E. Henault, N. G. Jensvold, and A. S. Go Gender Differences in the Risk of Ischemic Stroke and Peripheral Embolism in Atrial Fibrillation: The AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) Study Circulation, September 20, 2005; 112(12): 1687 - 1691. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Di Nisio, S. Middeldorp, and H. R. Buller Direct Thrombin Inhibitors N. Engl. J. Med., September 8, 2005; 353(10): 1028 - 1040. [Full Text] [PDF]
|
|
|
|
|
|
M. P. Gulseth Ximelagatran: An orally active direct thrombin inhibitor Am. J. Health Syst. Pharm., July 15, 2005; 62(14): 1451 - 1467. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. H. Veloso, R. de Janeiro, A. A. V. de Paola, and D. E. Singer Clopidogrel as Antithrombotic Therapy in Atrial Fibrillation Chest, July 1, 2005; 128(1): 475 - 475. [Full Text] [PDF]
|
|
|
|
|
|
R. H. Falk Rate Control Is Preferable to Rhythm Control in the Majority of Patients With Atrial Fibrillation Circulation, June 14, 2005; 111(23): 3141 - 3150. [Full Text] [PDF]
|
|
|
|
|
|
M. E. Goldman and L. B. Croft Atrial Fibrillation: The Ancient Conundrum Defies Simple Solution J. Am. Coll. Cardiol., June 7, 2005; 45(11): 1813 - 1814. [Full Text] [PDF]
|
|
|
|
|
|
M. Ogren, D. Bergqvist, H. Eriksson, B. Lindblad, and N. H. Sternby Prevalence and risk of pulmonary embolism in patients with intracardiac thrombosis: a population-based study of 23 796 consecutive autopsies Eur. Heart J., June 1, 2005; 26(11): 1108 - 1114. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Y.H. Lip Stroke prevention in atrial fibrillation: the case for ximelagatran Eur. Heart J. Suppl., June 1, 2005; 7(suppl_E): E21 - E25. [Full Text] [PDF]
|
|
|
|
|
|
P. M.W. Bath, L. Zhao, and S. Heptinstall Current status of stroke prevention in patients with atrial fibrillation Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C12 - C18. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. O'Donnell, G. Agnelli, and J. I. Weitz Emerging therapies for stroke prevention in atrial fibrillation Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C19 - C27. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Emmerich, J.-Y. Le Heuzey, P. M.W. Bath, and S. J. Connolly Indication for antithrombotic therapy for atrial fibrillation: reconciling the guidelines with clinical practice Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C28 - C33. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Schulman and R. J. Beyth Risk of bleeding with long-term antithrombotic therapy in atrial fibrillation Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C34 - C40. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. S.J. Miller, M. F. Drummond, L. K. Langkilde, J. J.V. McMurray, and M. Ogren Economic factors associated with antithrombotic treatments for stroke prevention in patients with atrial fibrillation Eur. Heart J. Suppl., May 1, 2005; 7(suppl_C): C41 - C54. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. F. Scholten, A. S. Thornton, J. M. Mekel, P. J. Koudstaal, and L. J. Jordaens Anticoagulation in atrial fibrillation and flutter Europace, January 1, 2005; 7(5): 492 - 499. [Abstract] [Full Text] [PDF]
|
|
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
