Anticoagulation decisions for patients with atrial fibrillation

This review recently appeared in the Cleveland Clinic Journal of Medicine. It centers around the updated guidelines promulgated last year by the American Heart Association, American College of Cardiology, and Heart Rhythm Society.

Although it's pretty much the usual rundown, a few points of particular interest are noteworthy:

The new guidelines favor risk assessment using the CHA2DS2-VASc score instead of CHADS2.

HAS-BLED should not be used to exclude patients from anticoagulation therapy.

This is because in all patients except for those at the very lowest risk for thromboembolism the risk of stroke exceeds the risk of intracranial bleeding. Low risk patients will be excluded by the CHA2DS2-VASc score. That being said, HAS-BLED can be useful in identifying patients in need of closer monitoring.

Diminishing importance of aspirin in the guidelines

From the review:

Aspirin has been compared with placebo in seven randomized controlled trials. Only the original SPAF study, in which aspirin 325 mg/day was used, found that it was beneficial. This result alone accounted for the 19% reduction in relative risk (95% CI 1%–35%, P less than .05) in a meta-analysis performed by Hart et al.29 Even when combined with clopidogrel 75 mg/day, aspirin 75 to 100 mg/day is still inferior to warfarin.5 While dual antiplatelet therapy resulted in a 28% relative reduction in thromboembolism (95% CI 17%–38%, P less than .01) compared with aspirin alone, major bleeding significantly increased by 57% (95% CI 29%–92%, P less than .01)...

The 2014 guidelines downgraded the recommendation for aspirin therapy. For patients at low risk and for some at intermediate risk, it is permissible to forgo therapy altogether, including aspirin.1

Patients with hypertrophic cardiomyopathy warrant special consideration.

Patients with AF who also have HCM should receive systemic anticoagulation regardless of the CHA2DS2-VASc score, as a class I recommendation in the new guidelines. This can be done with either TSOACs or warfarin.