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Risk Stratification - Antithrombotic Therapy for Patients With Atrial Fibrillation

Although schemes for stratification of stroke risk identify patients who benefit most and least from anticoagulation, the threshold for use of anticoagulation is still controversial. Our recommendations for antithrombotic therapy are summarized in the tables below.

Anticoagulation is recommended for 3 weeks prior to and 4 weeks after cardioversion for patients with atrial fibrillation (AF) of unknown duration or with AF for longer than 48 hours. Although left atrial thrombus and systemic embolism have been documented in patients with AF of shorter duration, the need for anticoagulation is less clear. When acute AF produces hemodynamic instability in the form of angina pectoris, MI, shock, or pulmonary edema, immediate cardioversion should not be delayed to deliver therapeutic anticoagulation, but intravenous unfractionated heparin or subcutaneous injection of a low-molecular-weight heparin should be initiated before cardioversion by direct-current countershock or intravenous antiarrhythmic medication.

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Risk Category	Recommended Therapy
No risk factors	Aspirin, 81-325 mg daily
One moderate risk factor	Aspirin, 81-325 mg daily or Warfarin (INR 2.0 to 3.0, target 2.5)
Any high risk factor or more than 1 moderate risk factor	Warfarin (INR 2.0 to 3.0, target 2.5)*

Less validated or weaker risk factors	Moderate risk factors	High risk factors
Female gender	Age 75 years or older	Previous stroke, TIA or embolism
Age 65-74 years	Hypertension	Mitral stenosis
Coronary artery disease	Heart failure	Prosthetic heart valve*
Thyrotoxicosis	LV ejection fraction less than 35%
	Diabetes mellitus

* indicates if mechanical valve, target INR greater than 2.5
INR indicates international normalized ratio; LV, left ventricular; TIA, transient ischemic attack.

ACC/AHA/ESC Pocket Guideline for the Management of Patients with Atrial Fibrillation; July 2007; 28-29.

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