Anticoagulation for Atrial Fibrillation in Specific Clinical Scenarios14
| Category | Recommendations |
|---|---|
| Stable CAD and PAOD | -DOAC mostly without use of antiplatelet agents |
| After coronary stenting | -Triple therapy with VKA (target INR, 2 to 2.5) or reduceddose DOAC*, aspirin 75 to 100 mg/d, and clopidogrel 75 mg /d |
| -Consider: bare metal stents, abbreviated 6-month dual antiplatelet therapy for drug eluting stent or omission of aspirin if bleeding propensity is high | |
| Secondary stroke prevention | -DOACs preferred over VKA unless TTR >70 |
| -No addition of antiplatelet agent to OAC is needed. | |
| Acute stroke | -r-tPA only if anticoagulation by test or history is minimal |
| -Mechanical thrombectomy for proximal intracranial occlusion | |
| Acute ischemic stroke after neuroimaging (repeat imaging pre-OAC for moderate to severe ischemic stroke) | - TIA start OAC immediately |
| - Mild ischemic stroke, start OAC after 3 days | |
| - Moderate ischemic stroke, start OAC at 5 to 7 days | |
| - Severe ischemic stroke, start OAC at 12 to 14 days | |
| History of GI bleed | -Preference to apixaban and low dose dabigatran |
| Hemodialysis | - VKA or no OAC (DOACs not approved if CrCl <15 mL/m) |
| Cardioversion | -VKA and DOACS appear to be similarly effective |
| AF- Ablation | -Preferred VKA over DOACS (limited data on edoxaban) |
| Mechanical valves | -VKA target INR based on valve type, site and associated conditions along with aspirin 75 to 100 mg daily |
| Mod/severe rheumatic mitral stenosis | VKA target INR 2 to 3 |
CAD, coronary artery disease; DAOC, direct oral anticoagulants; GI, gastrointestinal; AF, atrial fibrillation; TTR, Time in Therapeutic Range; OAC, oral anticoagulants; TIA; transient ischemic attack; r-tPA, recombinant tissue plasminogen activator; PAOD, peripheral arterial occlusive disease; VKA, vitamin K antagonists.
↵* Apixaban 2.5 mg BID.