How I use anticoagulation in atrial fibrillation

Atrial fibrillation is the most common cardiac arrhythmia and conveys a significant risk of morbidity and mortality due to related stroke and systemic embolism. Oral anticoagulation (OAC) is the mainstay of thromboembolism prevention, and management of anticoagulation can be challenging. For patients without significant valvular disease, decisions around anticoagulation therapy are first based on the presence of additional stroke risk factors, as measured by the CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74, and sex category [female]) score. Patients with increased CHA₂DS₂-VASc scores (by regional guidelines) should next be evaluated to determine if they are candidates for non-vitamin K antagonist oral anticoagulant (NOAC) therapy. This should focus on assessment of concomitant valve disease and/or impaired renal function. In eligible patients, the cumulative data support a preference for NOACs over warfarin, as NOACs appear safer and more effective as a group. However, there are no direct, randomized comparisons between NOACs, and therefore, selecting among them can be difficult. In addition, important patient groups remain underrepresented in major clinical trials, and their management is often left to clinician judgment. Data from emerging clinical trials will help guide physicians; however, patient engagement in decisions regarding OAC management will remain vital to ensuring appropriate balance of risks and optimizing health outcomes.