Great review by Cavallari et. al in Heart Rhythm Journal for a common clinical question.
•Deep stratification of thromboembolic risk is advisable, while also considering other possible predictors of increased risk beyond the CHA2DS2-VASc score, such as renal failure, left atrial enlargement, low flow in the left atrial appendage, different left atrial morphologies, and spontaneous echo-contrast.
•The clinical threshold at which anticoagulant therapy is associated with net clinical benefit seems to be an expected (untreated) stroke rate ≥1% per year.38 However, age 65 to 74 years represents a more powerful risk factor for stroke (with a >2.5-fold increase in the hazard ratio) than the other characteristics weighted as 1 point in the CHA2DS2-VASc score.3 Accordingly, the yearly stroke rate without antithrombotic therapy appears surely to be >1% in AF patients with CHA2DS2-VASc 1 due to age 65 to 74 years, whereas the rate is generally <1% in those with CHA2DS2-VASc 1 due to other variables. Thus, the latter patients are unlikely to derive a net benefit from routine use of anticoagulant therapy, unless renal failure, insulin-dependent diabetes, left atrial enlargement with spontaneous echo-contrast, or very low flow velocities in the left atrial appendage coexist. Conversely, anticoagulant treatment may represent the strategy of choice over antiplatelet or no antithrombotic therapy in patients with CHA2DS2-VASc 1 and age between 65 and 74 years. Of note, AF patients with CHA2DS2-VASc 1 due to only the presence of female gender actually are considered at very low risk of ischemic stroke (<1%/year) and do not require routine oral anticoagulation.39
•With regard to utilization of warfarin vs novel oral anticoagulants, the patient’s type of work and the patient’s preferences should be considered, and the latter agents might be preferred, especially in patients with high bleeding risk. However, cost-effectiveness analyses in this context are relevant and welcome.
•Careful evaluation of bleeding risk is crucial. Of note, the HAS-BLED score may range from 0 to 5 in patients with CHA2DS2-VASc score 1.
•Anticoagulant therapy may be withdrawn for short, well-defined time periods after coronary stenting and resumed after interruption of an antiplatelet agent.
•CHA2DS2-VASc is a dynamic score, and patients must be reassessed periodically for this measurement of thromboembolic risk.
•Future research investigating the possible role of new diagnostic tools (eg, global longitudinal left atrial strain, microembolic signals by transcranial Doppler) for improvement of thromboembolic risk stratification would be welcome.
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