Know Your Guidelines – Atrial Fibrillation

Adam WandermanGuideline Knowledge Check, Internal Medicine, Medical News

internal-medicine-guidelines-knowledge-check atrial fibrillation

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Today’s Guideline Knowledge Check question comes from the desk of Med-Challenger Internal Medicine Editor-in-Chief, Paul F. Griner, MD, MACP.

Based on the Just Published Recommendations of the American College of Chest Physicians …

For patients with atrial fibrillation, has the recommended stroke risk-stratification tool changed since the 2014 American Heart Association guidelines on the same subject?

Yes or No?

In November 2018, the American College of Chest Physicians published guidelines on antithrombotic therapy in atrial fibrillation, in which they supported the 2014 American Heart Association Class I recommendation to use the CHA2D2S-VASc score** instead of the formerly endorsed CHA2Ds scoring tool*.

However, the 2018 CHEST and 2014 AHA guidelines don’t agree on the therapeutic interventions for a given CHA2D2S-VASc risk score.

According to the 2014 AHA guidelines:

  • A patient with atrial fibrillation and a CHA2D2S-VASc score = 0 does not require antithrombotic medication.
  • A patient with a risk score of 1 can be managed with a choice of no antithrombotic medication, aspirin, or an oral anticoagulant.
  • A patient with a risk score of 2 or more should be managed with an oral anticoagulant such as warfarin or one of the 3 new oral anticoagulants (NOACs).
  • A patient with valvular atrial fibrillation should be managed with warfarin.

*CHADS2: 1 point each for: Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Prior Stroke or TIA or Thromboembolism (2 points)

**CHA2DS2-VASc (differences to CHADS2 score are highlighted): 1 point each for Congestive heart failure, Hypertension, Age ≥75 years (2 points), Diabetes mellitus, Prior Stroke or TIA or thromboembolism (2 points), Vascular disease, Age 65 to 74 years, Sex category (1 point for female, 0 points for male)

Try this review question and find out if you’re following the most current guideline.

Guideline Review Question

What therapeutic interventions are recommended in the 2018 CHEST guidelines for each respective patient population?

Answers:
Patients with atrial fibrillation and a CHA2D2S-VASc score of 0 should be managed with aspirin rather than receive no antithrombotic treatment at all.

Patients with atrial fibrillation and a CHA2D2S-VASc score of 1 (ignoring the male versus female point) should be managed with oral anticoagulants, preferably a NOAC.

For patients with atrial fibrillation and a CHA2D2S-VASc score of 2 or higher, a vitamin K agonist is preferable over a NOAC.

Patients with a mechanical valve and atrial fibrillation should be managed with a combination of clopidogrel and a NOAC.

Answer Explanation & References:


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About the Author:

Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He returned to Rochester as Chief Resident in Medicine and Hematology Fellow and remained in their Department of Medicine, rising to Professor. He served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine.

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