Practical Advice Related to Anticoagulation for Atrial Fibrillation: Beyond the Guidelines

Decisions regarding oral anticoagulation for patients with atrial fibrillation (AF) have become increasingly complex. The 2014 ACC/AHA/HRS AF Guidelines were an important update, are useful when making anticoagulation choices related to most patients with AF, and provide the important data and rationale behind the various classifications of recommendations.¹ However, the number of scenarios encountered in daily practice as a result of the aging population, the rise in patient comorbidities, the likelihood that such patients will need other procedures and surgeries, and the growing number of available anticoagulants and antiplatelet medications continue to increase. These trends call for a more practical guide for complex situations where multiple physicians are involved in the day-to-day care of the patient with AF and where data may be incomplete. In the April 2015 issue of the Journal of the American College of Cardiology (JACC), a roundtable panel convened by the American College of Cardiology to develop a practical approach to anticoagulation for patients with AF published the end product of their meeting.² The group attempted to address the following issues based on the literature and a consensus of panel members: 

1. Initiation and interruption of anticoagulant therapy;
2. Quality, cost, and team-based management of anticoagulation;
3. Management of bleeding and emergency care; and
4. Complex disease states and special populations. 

The JACC paper provides an up-to-date discussion of these issues, useful tables and figures, and practical advice. One of the more useful contributions is a flow chart that provides advice related to single vs. dual vs. triple therapy for patients with AF who have either previously undergone, or are about to undergo, coronary artery stenting.

The panel took efforts to make the recommendations as current as possible: “The discussion was supplemented with focused reviews of the English language published data in PubMed to November, 2014, that pertained to the roundtable themes.” However, any paper such as this will be partially obsolete at the time of publication. For example, the ORBIT-AF study that highlighted the risks of bridging patients who are anticoagulated was published in December 2014.³ A discussion of that trial would have helped the relatively sparse discussion on the topic of interruption of anticoagulation. In addition, there are places where the advice seems to adhere more to the FDA and manufacturer labeling rather than trying to be practical. For example, it is recommended, presumably to adhere to the package insert, that when transitioning a patient from warfarin to rivaroxaban, that the rivaroxaban should be started when the INR is <3. This recommendation does not seem to follow logic given the short time to onset of action of rivaroxaban. It would seem more logical to wait until the INR is at least <2.0. This conservative approach is likely a function of including representatives from the FDA and industry on the panel. Nevertheless, all providers of care to patients with anticoagulation should review the comprehensive “Practical Management of Anticoagulation in Patients With Atrial Fibrillation”. It is the type of document that should have laminated copies of its figures hanging in the workrooms of clinics and hospitals everywhere.

References

1. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:2246-2280.
2. Kovacs RJ, Flaker GC, Saxonhouse SJ, et al. Practical Management of Anticoagulation in Patients With Atrial Fibrillation. J Am Coll Cardiol. 2015;65(13):1340-1360. doi:10.1016/j.jacc.2015.01.049.
3. Steinberg BA, Peterson ED, Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488-494. doi: CIRCULATIONAHA.114.011777. Epub 2014 Dec 12.