Anticoagulants Case Study
The choice of anticoagulants depends on CHA2DS2-VASc score as follow,
CHA2DS2-VASc risk
Score
Congestive heart failure (any history)
1
Hypertension (prior history)
1
Age ≥75 years
2
Diabetes mellitus
1
Stroke/transient transient ischemic attack/thromboembolism history
2
Vascular disease (e.g., myocardial infarction, peripheral vascular disease or aortic plaque)
1
Age 65-74 years
1
Sex (female gender)
1
CHA2DS2-VASc of the patient in the question stem would be 1 (for congestive heart failure) + 1 (for hypertension) + 2 (for age >75 years), i.e., he has a total score of 4.
Interpretation of CHA2DS2-VASc score
Score of 0 or 1:
The decision to give long-term aspirin should be individualized as no major consensus for those patients.
The American Heart Association guidelines include aspirin as an option, while National Institute for Health and Care Excellence and European Society of Cardiology guidelines do not recommend it. …show more content…
Score >2:
Concomitant heparin and warfarin therapy until the warfarin levels are therapeutic (INR 2-3), then heparin is stopped.
Warfarin is given for 3-4 weeks before cardioversion and at least 4 weeks after cardioversion.
Direct oral anticoagulants are non-inferior to warfarin and can be used alone in non-valvular atrial fibrillation. They should not be given with warfarin, heparin or to patients with prosthetic valve or end stage renal disease. Examples include,
Direct thrombin inhibitors
(e.g.,dabigatran)
Direct factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban)
There are 2 long-term strategies in management of atrial fibrillation, which are rhythm control, or cardioversion (as mentioned above) and rate control which can be achieved by, β-blockers (e.g., esmolol, carvedilol) and/or calcium channel blockers (e.g., diltiazem, verapamil).
Digoxin or amiodarone in patients with congestive heart failure.
Evidence from multiple studies indicate no difference in clinical outcomes with rate or rhythm-control strategies, but meta-analysis suggests lower rehospitalization rates with rate control for all ages, and support for rhythm control in younger patients.
CHA2DS2-VASc risk
Score
Congestive heart failure (any history)
1
Hypertension (prior history)
1
Age ≥75 years
2
Diabetes mellitus
1
Stroke/transient transient ischemic attack/thromboembolism history
2
Vascular disease (e.g., myocardial infarction, peripheral vascular disease or aortic plaque)
1
Age 65-74 years
1
Sex (female gender)
1
CHA2DS2-VASc of the patient in the question stem would be 1 (for congestive heart failure) + 1 (for hypertension) + 2 (for age >75 years), i.e., he has a total score of 4.
Interpretation of CHA2DS2-VASc score
Score of 0 or 1:
The decision to give long-term aspirin should be individualized as no major consensus for those patients.
The American Heart Association guidelines include aspirin as an option, while National Institute for Health and Care Excellence and European Society of Cardiology guidelines do not recommend it. …show more content…
Score >2:
Concomitant heparin and warfarin therapy until the warfarin levels are therapeutic (INR 2-3), then heparin is stopped.
Warfarin is given for 3-4 weeks before cardioversion and at least 4 weeks after cardioversion.
Direct oral anticoagulants are non-inferior to warfarin and can be used alone in non-valvular atrial fibrillation. They should not be given with warfarin, heparin or to patients with prosthetic valve or end stage renal disease. Examples include,
Direct thrombin inhibitors
(e.g.,dabigatran)
Direct factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban)
There are 2 long-term strategies in management of atrial fibrillation, which are rhythm control, or cardioversion (as mentioned above) and rate control which can be achieved by, β-blockers (e.g., esmolol, carvedilol) and/or calcium channel blockers (e.g., diltiazem, verapamil).
Digoxin or amiodarone in patients with congestive heart failure.
Evidence from multiple studies indicate no difference in clinical outcomes with rate or rhythm-control strategies, but meta-analysis suggests lower rehospitalization rates with rate control for all ages, and support for rhythm control in younger patients.