ESC Congress FA eBook 2016 - 4

FEATURED ARTICLE

Figure 2. Stroke Prevention in Atrial Fibrillation.
Mechanical heart valves or moderate or severe mitral
stenosis

Yes

Estimate stroke risk based on number of
CHA 2DS 2-VASc risk factors
0a
No antiplatelet
or anticoagulant
treatment (IIIB)

OAC should be
considered (IIaB)

≥ 2b
Oral anticoagulation indicated
Assess for contra-indications
Correct reversible bleeding
risk factors

LAA occluding devices
may be considered in
patients with clear contraindications for OAC (IIbC)

NOAC (IA)

VKA (IA) c

Includes women without other stroke risk factors
b IIaB for women with only one additional stroke risk factor
c IB for patients with mechanical heart valves or mitral stenosis
a

AF, atrial fibrillation; LAA, left atrial appendage; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; VKA, vitamin K antagonist.
Reprinted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210.
By permission of Oxford University Press on behalf of the European Society of Cardiology.

Table 3 Recommendations for Stroke Prevention in Patients With AF
Recommendations

Class

Level

OAC therapy to prevent thromboembolism is recommended for all male AF patients with a CHA2DS2-VASc score of 2 or more.

OAC therapy to prevent thromboembolism is recommended in all female AF patients with a CHA2DS2-VASc score of 3 or
more.

OAC therapy to prevent thromboembolism should be considered in make AF patients with a CHA2DS2-VASc score of 1,
considering individual characteristics and patient preferences.

IIa

OAC therapy to prevent thromboembolism should be considered in female AF patients with a CHA2DS2-VASc score of 2,
considering individual characteristics and patient preferences.

IIa

VKA therapy (INR 2.0-3.0 or higher) is recommended for stroke prevention in AF patients with moderate to severe mitral
stenosis or mechanical heart valves.

When OAC therapy is initiated in a patient with AF who is eligible for a NOAC (apixaban, dabigatran, edoxaban, or
rivaroxaban), a NOAC is recommended in preference to a VKA.

When patients are treated with a VKA, TTR should be kept as high as possible and closely monitored.

IIb

Combinations of OACs and platelet inhibitors increase bleeding risk and should be avoided in AF patients without another
indication for platelet inhibition.

III
(harm)

In male or female AF patients without additional stroke risk factors, anticoagulant or antiplatelet therapy is not
recommended for stroke prevention.

III
(harm)

Antiplatelet monotherapy is not recommended for stroke prevention in AF patients, regardless of stroke risk.

III
(harm)

NOACs are not recommended in patients with mechanical heart valves (LOE B) or moderate to severe mitral stenosis
(LOE C).

III
(harm)

AF patients already on treatment with a VKA may be considered for NOAC therapy if TTR is not well controlled despite good
adherence, or if patient preference without contraindications to NOACs.

AF, atrial fibrillation; LOE, level of evidence; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; TTR, time in therapeutic range; VKA, vitamin K antagonist.
Reprinted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210. By
permission of Oxford University Press on behalf of the European Society of Cardiology.

October 2016

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Table of Contents for the Digital Edition of ESC Congress FA eBook 2016