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Which patients need anticoagulation?

Anticoagulation should be offered to all patients with a CHA2DS2-VASc score ≥2 – taking bleeding risk into account – to help protect them from strokes.1,2 Anticoagulation should also be considered for men with a CHA2DS2-VASc score ≥1.1

CHA2DS2-VASc and HAS-BLED

The CHA2DS2-VASc score assesses the risk of stroke in patients with AF and determines the need for anticoagulation. Alongside this, bleeding risk should be assessed using the HAS-BLED score.1,2

PFI_ELI_NVAF_UK

Adapted from Camm et al. 2010.2

*Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporary cohorts may vary from these estimates.

PFI_ELI_NVAF_UK

Adapted from Camm et al. 2010.2

*Hypertension is defined as systolic blood pressure >160 mmHg. Abnormal kidney function is defined as the presence of chronic dialysis or renal transplantation or serum creatinine ≥200 µmol/L. Abnormal liver function is defined as chronic hepatic disease (e.g. cirrhosis) or biochemical evidence of significant hepatic derangement (e.g. bilirubin >2 x upper limit of normal, in association with aspartate aminotransferase / alanine aminotransferase / alkaline phosphatase >3 x upper limit normal, etc.). Bleeding refers to previous bleeding history and / or predisposition to bleeding, e.g. bleeding diathesis, anaemia, etc. Labile INRs refers to unstable / high INRs or poor time in therapeutic range (e.g. <60%). Drugs / alcohol use refers to concomitant use of drugs, such as antiplatelet agents, non-steroidal anti-inflammatory drugs, or alcohol abuse, etc.

The HAS-BLED score should not be used on its own to exclude patients from anticoagulation, but to highlight those in whom caution should be taken and to help identify bleeding risk factors that may be modified.3 A HAS-BLED score of ≥3 indicates a high risk of bleeding. Such patients should be anticoagulated with caution and have regular reviews.2,3 The following bleeding risk factors should be monitored and controlled:1,3

  • Uncontrolled hypertension
  • Poor INR control
  • Concurrent medication e.g., aspirin or NSAIDs
  • Harmful alcohol consumption

Patient preference should also be considered. Often, patients are willing to accept a higher bleeding risk to protect them from stroke.3 Education is essential so that the decision to anticoagulate or not can be made by informed patients.3

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Click here to view ELIQUIS (apixaban) prescribing and adverse event reporting information.

Abbreviations

AF = Atrial Fibrillation CHA2DS2-VASc = Congestive Heart Failure, Hypertension, Age (double if ≥75), Diabetes, Stroke or TIA (double), Vascular disease, Sex CrCl = Creatinine Clearance HAS-BLED = Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol INR = International Normalised Ratio NOAC = Non-VKA Oral Anticoagulant NSAID = Nonsteroidal Anti-Inflammatory Drug

References
  1. NICE. CG180. 2014. Available at: https://www.nice.org.uk/guidance/cg180. Accessed August 2019.
  2. Camm AJ et al. Eur Heart J 2010; 31: 2369–2429.
  3. Lane DA & Lip GYH. Circulation 2012; 126: 860–865.

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Job code: 432UK1900440-01
Date of preparation: September 2019

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