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Section 16:
Anticoagulation for the Long-term Management of Atrial Fibrillation
Anticoagulation for the
Long-term Management of AF
Discussion Points
? Review the results of the stroke-prevention
trials in AF
? Discuss the risks/benefits of antithrombotic therapy
? Review the current guidelines for anticoagulation therapy pre- and post-cardioversion
Multiple Thrombi in AF
AF Investigators: Meta-analysis
Patient Characteristics
AF Investigators: Meta-analysis
Warfarin for Stroke Prevention
AF Investigators: Meta-analysis
Bleeding Rates
Risk-Stratification Schemes
AFI AnalysisSPAF III
High-Risk Prior TIA/stroke ?Prior TIA/stroke
Features (RF) ?History of hypertensionSystolic BP >160 mmHg ?DiabetesImpaired LV function* ?Increasing age ?Women >75 y
Rate of Ischemic Stroke
or Systemic Embolism
Anticoagulation and Stroke Risk
Underutilization of Warfarin
Anticoagulation Guidelines for Cardioversion
?AF >48 hours?duration
- Pre-cardioversion: 3 weeks?anticoagulation
- Post-cardioversion: 4 weeks?anticoagulation
? Target INR, 2.5; range, 2?
? Manage atrial flutter similarly to AF
AgeRisk Factors* Recommendation
<65 yAbsentAspirin
PresentWarfarin?
65?5 yAbsentAspirin or warfarin
PresentWarfarin
>75 yAll patientsWarfarin
Frequently Asked Questions
1. Is aspirin effective for preventing stroke in AF?
2. When should a patient with acute AF be anticoagulated?
Answers
1. Is aspirin effective for preventing stroke in AF?
- Yes. However not as effective as warfarin.
2. When should a patient with acute AF be anticoagulated?
- AF <48 hours: cardioversion without anticoagulation
- AF >48 hours:
? Pre-cardioversion: 3 weeks?anticoagulation or heparin and TEE
? Post-cardioversion: 3 weeks?anticoagulation
Common Misconceptions
? All patients with AF require anticoagulation.
? Stop warfarin in patients who have been back in sinus rhythm for 3 months and are well controlled on antiarrhythmic therapy.
? Since there is an increased risk of bleeding with warfarin, it should not be used in elderly patients.
Section 16:
Anticoagulation for the Long-term Management of Atrial Fibrillation
Anticoagulation for the
Long-term Management of AF
Discussion Points
? Review the results of the stroke-prevention
trials in AF
? Discuss the risks/benefits of antithrombotic therapy
? Review the current guidelines for anticoagulation therapy pre- and post-cardioversion
Multiple Thrombi in AF
AF Investigators: Meta-analysis
Patient Characteristics
AF Investigators: Meta-analysis
Warfarin for Stroke Prevention
AF Investigators: Meta-analysis
Bleeding Rates
Risk-Stratification Schemes
AFI AnalysisSPAF III
High-Risk Prior TIA/stroke ?Prior TIA/stroke
Features (RF) ?History of hypertensionSystolic BP >160 mmHg ?DiabetesImpaired LV function* ?Increasing age ?Women >75 y
Rate of Ischemic Stroke
or Systemic Embolism
Anticoagulation and Stroke Risk
Underutilization of Warfarin
Anticoagulation Guidelines for Cardioversion
?AF >48 hours?duration
- Pre-cardioversion: 3 weeks?anticoagulation
- Post-cardioversion: 4 weeks?anticoagulation
? Target INR, 2.5; range, 2?
? Manage atrial flutter similarly to AF
AgeRisk Factors* Recommendation
<65 yAbsentAspirin
PresentWarfarin?
65?5 yAbsentAspirin or warfarin
PresentWarfarin
>75 yAll patientsWarfarin
Frequently Asked Questions
1. Is aspirin effective for preventing stroke in AF?
2. When should a patient with acute AF be anticoagulated?
Answers
1. Is aspirin effective for preventing stroke in AF?
- Yes. However not as effective as warfarin.
2. When should a patient with acute AF be anticoagulated?
- AF <48 hours: cardioversion without anticoagulation
- AF >48 hours:
? Pre-cardioversion: 3 weeks?anticoagulation or heparin and TEE
? Post-cardioversion: 3 weeks?anticoagulation
Common Misconceptions
? All patients with AF require anticoagulation.
? Stop warfarin in patients who have been back in sinus rhythm for 3 months and are well controlled on antiarrhythmic therapy.
? Since there is an increased risk of bleeding with warfarin, it should not be used in elderly patients.
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