Non–Emergency Department Pathways
European Heart Rhythm Association (EHRA): 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation (Steffel et al, EP Europace 2021)
This updated guidance, published by the EHRA in 2021, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between other anticoagulants and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Special considerations for DOAC use during the COVID-19 pandemic are also included. Sample pathways to help guide decision-making are included for various clinical scenarios.
Novel Bleeding Risk Score for Patients With Atrial Fibrillation on Oral Anticoagulants, Including Direct Oral Anticoagulants (Adam et al, J Thromb Haemostat 2021 and SUPPL)
This article describes the development and internal validation of a novel bleeding risk prediction model for AF patients taking oral anticoagulants, including DOACs and vitamin K antagonists. The model was derived from a large, prospective, population-based cohort study of AF patients, the majority of whom were using DOACs. The patients were at low risk of bleeding and could safely use and benefit from anticoagulants. Also included were patients at high risk of bleeding after controlling for known bleeding risk factors. The model may also be useful in identifying patients who would benefit from more frequent clinical monitoring for signs of occult bleeding or DOAC dose adaptation.
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Expert Consensus Decision Pathway of the American College of Cardiology on Management of Bleeding in Patients With Oral Anticoagulants: A Review of the 2020 Update for Perioperative Physicians (Navas-Blanco et al, J Cardiothorac Vasc Anesth 2021)
This is an update to the American College of Cardiology's 2017 Expert Consensus Decision Pathway (ECDP) and focuses on bleeding in patients on DOACs, including point-of-care testing devices, lab monitoring of anticoagulation status, novel reversal agents, and reversal strategies. This ECDP has updates that are relevant for perioperative physicians, who often encounter bleeding patients taking DOACs. An algorithm for the ECDP for bleeding management in patients taking DOACs is presented to guide decisions regarding discontinuation of DOACs, reinitiation of anticoagulation, and administration of reversal or hemostatic agents. Overall, the consensus panel emphasizes that reinitiation of DOAC therapy provides an overall benefit.
Direct Oral Anticoagulant Choice for Stroke Prevention in Obese Patients With Atrial Fibrillation (Brar and Chua, Can J Cardiol 2021)
The efficacy and safety of the 4 DOACs approved for NVAF (dabigatran, rivaroxaban, apixaban, and edoxaban) in obese patients are not clear. The best evidence for choosing DOACs in obese patients with AF is based on obese subgroup analyses of major landmark DOAC clinical trials and meta-analyses and from International Society of Thrombosis and Haemostasis 2016 recommendations. In this review, the authors build on that evidence to propose a BMI-based algorithm to guide clinicians in the use of DOACs in obese individuals with AF. The authors also describe caveats to consider when choosing a DOAC for patients with BMI greater than 50 kg/m2.
Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: Safety Issues in the Elderly (Ajam et al, Expert Rev Clin Pharmacol 2020)
This article reviews the use of direct oral anticoagulants (DOACs) in elderly patients with atrial fibrillation (AF), high risk of stroke and bleeding, and comorbidities requiring polypharmacy. The safety, efficacy, pharmacokinetics, pharmacodynamics, drug-drug interactions, and drug-food interactions of DOACs are described. Clinical studies, guidelines for the management of AF, and expert consensus statements of US and European societies of cardiovascular diseases and cardiac electrophysiology are also reviewed. The article addresses specific challenges with the use of DOACs, including bleeding management and reversal, switching between anticoagulants (vitamin K antagonists and DOACs), and use of DOACs in patients with AF and renal impairment.
Canadian Cardiovascular Society (CSC): The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation (Andrade et al, Can J Cardiol [CJC] 2020 and SUPPL)
The Canadian Cardiovascular Society, in collaboration with the Canadian Heart Rhythm Society, provides comprehensive evidence-based recommendations for the use of vitamin K antagonists and direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including those with chronic kidney disease (CKD), end-stage renal disease (ESRD), coronary artery disease, liver disease, advanced age, frailty, or increased body mass index (BMI), and in those undergoing cardioversion, catheter ablation, or other invasive procedures. The guidelines also provide recommendations on the prevention and management of DOAC-associated bleeding events. Several clinical pathways to help guide anticoagulation therapy decision-making in various clinical scenarios are provided.
Anticoagulation in Atrial Fibrillation (Barra and Providência, Heart 2020)
In this narrative review, the authors provide an algorithm for selecting the appropriate anticoagulant according to age, renal or hepatic impairment, bleeding risk, and other characteristics. The article also presents recommendations on how to adjust DOAC dosage in patients with renal impairment. The article includes a flowchart to guide the clinician in the management of active bleeding events, categorized by bleeding severity, in AF anticoagulated patients.
Tailoring Anticoagulant Treatment of Patients With Atrial Fibrillation Using a Novel Bleeding Risk Score (Chu et al, Heart 2020)
VTE-BLEED (ActiVe cancer, male with uncontrolled hyperTension, anEmia, history of BLeeding, agE and rEnal Dysfunction) is a bleeding risk score that predicts major bleeding and has been used for patients with venous thromboembolism (VTE). In patients with atrial fibrillation (AF), VTE-BLEED was recalibrated to AF-BLEED and identified patients at high risk of bleeding.
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European Society of Cardiology (ESC): 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration with the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the Diagnosis and Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Developed with the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC (Hindricks et al, Eur Heart J 2020 and SUPPL)
The ESC, in collaboration with the EACTS and developed with the EHRA, updated its 2016 guidelines for the screening, diagnosis, assessment, and management of atrial fibrillation (AF) in patients with or without comorbid cardiovascular disease (CVD), including valvular heart disease (direct oral anticoagulants [DOACs] are not indicated for use in patients with mechanical heart valves). Options for rate and rhythm control are described. Strategies for minimizing bleeding risk and managing bleeding episodes (including reversal options) are included, as are recommendations for periprocedural management of anticoagulation, including in patients undergoing ablation or cardioversion. Risks and benefits of DOACs and vitamin K antagonists (VKAs) are highlighted. Sample pathways to help guide decision-making are included for various clinical scenarios. These guidelines also include quality and performance indicators that may be used to evaluate the level of implementation of the guidelines and identify opportunities for improvement.
Stroke Prevention Strategies in High-Risk Patients With Atrial Fibrillation (Kotalczyk et al, Nat Rev Cardiol 2020)
This article provides an overview of the use of vitamin K antagonists and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) who are at high risk of stroke and bleeding and have been under-represented or not studied in randomized clinical trials. The focus of this review includes patients with AF who also have end-stage renal disease (ESRD), are elderly (aged >80 years) with multiple risk factors for bleeding, or who had a previous intracranial bleed or recent acute bleed (such as a gastrointestinal bleed). An algorithm for the reinitiation of anticoagulation in patients with AF and previous major bleeding is provided.
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Complex Clinical Scenarios With the Use of Direct Oral Anticoagulants in Patients With Atrial Fibrillation: A Multidisciplinary Expert Advisory Board (Mulder et al, Neth Heart J 2020)
A Dutch cardiovascular advisory board summarized published data on complex clinical situations that are encountered in practice but are not clearly addressed in treatment guidelines. The advisory board formulated recommendations and presented hypothetical case scenarios to aid clinicians in decision-making in such settings. Finally, a framework for initiating direct oral anticoagulants (DOACs) is proposed.
Canadian Cardiovascular Society (CCS): Society Guidelines: 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation (Andrade et al, Can J Cardiol [CJC] 2018 and SUPPL)
This updated guidance, published by the EHRA in 2018, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between vitamin K antagonists and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Sample pathways to help guide decision making are included for various clinical scenarios.
Navigating the Choice of Oral Anticoagulation Therapy for Atrial Fibrillation in the NOAC Era (Hammersley and Signy, Ther Adv Chronic Dis [TACD] 2017)
This narrative review includes an overview of the risks and benefits of direct oral anticoagulants (DOACs) and patient-specific considerations that may influence selection of one DOAC over another.
European Society of Cardiology (ESC): 2016 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration With EACTS (Kirchhof et al, Eur Heart J [EHJ] 2016)
The 2016 ESC guidelines outline management strategies for patients with AF (with or without comorbid cardiovascular disease [CVD], including valvular heart disease [direct oral anticoagulants (DOACs) are not indicated for use in patients with mechanical heart valves]). Options for rate and rhythm control are described. Anticoagulant dosing adjustments in patients with renal impairment are provided. Strategies for minimizing bleeding risk and managing bleeding episodes (including reversal options) are included, as are recommendations for periprocedural management of anticoagulation, including in patients undergoing ablation or cardioversion. Risks and benefits of vitamin K antagonists and DOACs are highlighted. Sample pathways to help guide decision making are included for various clinical scenarios.
European Primary Care Cardiovascular Society (EPCCS): European Primary Care Cardiovascular Society (EPCCS) Consensus Guidance on Stroke Prevention in Atrial Fibrillation (SPAF) in Primary Care (Hobbs et al, Eur J Prev Cardiol [EJPC] 2016 and SUPPL)
This consensus statement, published in 2016, offers primary care providers evidence-based guidance on reduction of stroke risk in patients with AF. A sample pathway for anticoagulation assessment and initiation and comparisons of the safety and efficacy of vitamin K antagonists and direct oral anticoagulants (DOACs) are provided. The online supplement provides additional details about each section of the publication and offers dosing guidance for DOACs in patients with renal impairment.
Individualized Approaches to Thromboprophylaxis in Atrial Fibrillation (Ziff and Camm, Am Heart J [AHJ] 2016)
This narrative review describes various patient characteristics that may influence selection of an appropriate DOAC, including renal impairment, age, risk of bleeding, and concomitant CVD.
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Choosing the Right Drug to Fit the Patient When Selecting Oral Anticoagulation for Stroke Prevention in Atrial Fibrillation (Shields and Lip, J Intern Med [JIM] 2015)
This narrative review includes a sample pathway for the initiation of anticoagulation in patients with AF using the CHA2DS2-VASc and HAS-BLED risk assessment tools to help guide therapy. Patient-specific characteristics that may influence selection or dosing of a specific direct oral anticoagulant (DOAC), such as renal impairment, age, and comorbid cardiovascular disease (CVD), are described.
Northwestern University Feinberg School of Medicine: Development of a Shared Decision-Making Tool to Assist Patients and Clinicians With Decisions on Oral Anticoagulant Treatment for Atrial Fibrillation (Kaiser et al, Curr Med Res Opin [CMRO] 2015)
Northwestern University Feinberg School of Medicine designed a decision aid tool to help guide selection of an appropriate anticoagulant in patients with AF. This interactive decision aid incorporates patients’ stroke and bleeding risks and preferences and is designed to be used as a tool during shared-decision making discussions with patients.
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University of Cincinnati: Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for Shared Decision Making (Eckman et al, Curr Med Res Opin [CMRO] 2015)
The University of Cincinnati designed an interactive decision aid tool to help guide selection of an appropriate anticoagulant in patients with AF. The Atrial Fibrillation Guideline Support Tool, or AFGuST, was designed to facilitate shared decision making discussions with patients and to incorporate patients’ stroke and bleeding risks, measured by CHA2DS2-VASc and HAS-BLED, respectively, along with their preferences regarding health-related outcomes.
University of Wisconsin Hospital and Clinics: Analysis of Anticoagulant Prescribing in Non-valvular Atrial Fibrillation and Development of a Clinical Tool for Guiding Anticoagulant Selection (Garber et al, J Thromb Thrombolysis 2015)
The University of Wisconsin Hospital and Clinics designed a clinical pathway, based on the 2012 ACCP guidelines, for initiation of anticoagulation therapy in patients with new-onset NVAF.
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University of North Texas Health Science Center: Pharmacology, Benefits, Unaddressed Questions, and Pragmatic Issues of the Newer Oral Anticoagulants for Stroke Prophylaxis in Non-valvular Atrial Fibrillation and Proposal of a Management Algorithm (Rosanio et al, Int J Cardiol 2014)
This narrative review provides an overview of the pharmacology, efficacy, and safety of direct oral anticoagulants (DOACs) in patients with NVAF. The evidence-based anticoagulation management pathway used at the University of North Texas Health Science Center is provided, along with recommendations for anticoagulation in patients with renal impairment, the elderly, patients with AF and comorbid acute coronary syndromes (ACS) and/or undergoing coronary stenting, and patients planning to undergo ablation.
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