AF: oral anticoagulation decision
Adults with ECG-confirmed AF. Pregnancy or children: seek specialist advice.
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CardiologyManagement
AF Anticoagulation Decision (ESC 2024)
AF Anticoagulation Decision (ESC 2024): AF: oral anticoagulation decision → Acute ischaemic stroke or recent thrombolysis: stroke team sets OAC start → ...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Warning Acute ischaemic stroke or recent thrombolysis: stroke team sets OAC start
Do not start OAC on the stroke score alone. If there is no acute stroke, go on to the valve question.
- Start OAC only after brain imaging excludes bleeding
- ELAN trial (cited by ESC 2024, no class of recommendation): DOAC within 48 h after minor or moderate stroke, or day 6-7 after major stroke, did no worse than later start
- Recent thrombolysis or thrombectomy: stroke team advice before any anticoagulant
03Decision Mechanical heart valve or moderate-severe mitral stenosis?
Bioprosthetic valve, TAVI and other valve disease: answer No. ESC 2024: a DOAC can be used. AU PIs: dabigatran contraindicated with a prosthetic valve; apixaban and rivaroxaban not recommended.
- If Yes
04Warning Mechanical valve or moderate-severe mitral stenosis: warfarin, not a DOAC
DOACs did worse than warfarin in trials in these patients. Anticoagulate whatever the CHA2DS2-VA score.
- Mechanical valve: INR target by valve type and position; cardiology advice
- Moderate-severe mitral stenosis: target INR 2.0-3.0
- Active bleeding, any prior intracranial bleed or pregnancy: specialist advice first
05Outcome Warfarin started (mechanical valve or MS)
Manage bleeding risk: BP, alcohol, unneeded antiplatelets or NSAIDs. Keep time in therapeutic range above 70%. Review INR plan with cardiology.
If No06Decision Hypertrophic cardiomyopathy (HCM) or cardiac amyloidosis?
Yes: anticoagulate whatever the CHA2DS2-VA score (ESC Class I).
- If Yes
07Action Score 2 or more, or HCM or cardiac amyloidosis: start oral anticoagulation
Recommended (ESC Class I). Use a DOAC in preference to warfarin.
- Antiplatelet therapy is not an alternative to anticoagulation
- Stop antiplatelets in most patients when OAC starts; cardiology advice if recent ACS or stent
- Bleeding risk is rarely a reason to withhold OAC
08Warning Before starting a DOAC: check exclusions
Check CrCl (Cockcroft-Gault), liver function and interacting drugs. Mechanical valve or moderate-severe mitral stenosis: warfarin, not a DOAC. Bioprosthetic valve or TAVI: no dabigatran (AU PI contraindication); apixaban and rivaroxaban not recommended in AU PIs; specialist advice.
- Active major bleeding or recent intracranial bleed: do not start. Any earlier intracranial bleed: specialist advice first. AU PI: no dabigatran after any intracranial, intraocular, spinal, retroperitoneal or atraumatic joint bleed, or a GI bleed in the past year (unless its cause was removed)
- Liver disease with coagulopathy and bleeding risk, including Child-Pugh C: no DOAC; specialist advice. AU PI: no rivaroxaban in Child-Pugh B with coagulopathy; no dabigatran if liver disease may affect survival
- Pregnancy, or antiphospholipid syndrome with prior thrombosis: no DOAC; specialist advice
09Warning Interacting drugs: check before choosing a DOAC
Avoid any DOAC with rifampicin, carbamazepine, phenytoin or St John's wort (low DOAC levels).
- No apixaban with ketoconazole or ritonavir
- No dabigatran with ketoconazole, itraconazole, ciclosporin or dronedarone
- Verapamil with dabigatran: see the dabigatran dose line
10Action Choose DOAC and adult dose
Use the full dose unless that drug's own reduction criteria are met. Under-dosing raises stroke risk without less bleeding. Warfarin if a DOAC is not suitable: target INR 2.0-3.0; switch to a DOAC if time in range <70%.
- Apixaban 5 mg twice daily. 2.5 mg twice daily only if 2 or more of: age 80 y or more, weight 60 kg or less, creatinine 133 umol/L or more. AU PI: not if CrCl <25 mL/min or on dialysis
- Rivaroxaban 20 mg once daily with food. 15 mg once daily if CrCl 15-49 mL/min. Not if CrCl <15 mL/min
- Dabigatran 150 mg twice daily. 110 mg twice daily if age 75 y or more (AU PI; ESC: 80 y or more). Consider 110 mg if CrCl 30-50 mL/min. Not if CrCl <30 mL/min. Verapamil: ESC 110 mg twice daily; AU PI no dose change, give dabigatran 2 h before verapamil for the first 3 days
- Edoxaban 60 mg once daily; 30 mg if CrCl 15-50 mL/min, weight 60 kg or less, or on ciclosporin, dronedarone, erythromycin or ketoconazole. No heparin lead-in in AF. Not TGA-registered
11Action All patients on OAC: manage modifiable bleeding risk
Do not use a bleeding risk score to withhold or stop OAC (ESC Class III).
- Control blood pressure
- Reduce excess alcohol
- Stop antiplatelets and NSAIDs that are not needed
- Warfarin: keep time in therapeutic range above 70%
- Review more often if bleeding risk factors cannot be changed
12Outcome Anticoagulation started
Review at least yearly: kidney function, weight, dose, adherence, bleeding and stroke risk. Before scheduled cardioversion: at least 3 weeks of therapeutic OAC, or TOE.
If No13Action No mechanical valve, MS, HCM or amyloidosis: calculate CHA2DS2-VA score (0-8)
HCM or cardiac amyloidosis: anticoagulate at any score. Do not use the AF pattern (paroxysmal, persistent, permanent) to decide.
- A2: age 75 years or older (+2). S2: prior stroke, TIA or arterial thromboembolism (+2)
- C: heart failure (any LVEF) or LVEF 40% or less (+1). H: hypertension, BP >140/90 mmHg twice or on treatment (+1)
- D: diabetes mellitus (+1). V: vascular disease: MI, CAD, PAD or complex aortic plaque (+1)
- A: age 65-74 years (+1). Female sex is not scored (ESC 2024)
14Decision CHA2DS2-VA score?
- 2 or more
- Path rejoins step 07Shared downstream outcome
- 1
15Action Score 1: consider oral anticoagulation
Should be considered (ESC Class IIa). Shared decision. If OAC is chosen, use the DOAC exclusion and dose steps. If not, reassess at each review.
- Discuss stroke and bleeding risk with the patient
- Other stroke risk markers favour OAC (e.g. cancer, chronic kidney disease)
- Cardioversion: if AF 24 h or more or unknown onset, 3 weeks of therapeutic OAC or TOE first; OAC for at least 4 weeks after
- OAC chosen
- Path rejoins step 08Shared downstream outcome
- OAC not chosen
16Outcome No long-term anticoagulation now
Score 0 (no HCM or cardiac amyloidosis), or score 1 with OAC not chosen. Reassess CHA2DS2-VA at each review and when new risk factors appear.
- 0
17Action Score 0: no long-term OAC for stroke prevention
Reassess stroke risk at each review.
- HCM or cardiac amyloidosis: anticoagulate at any score
- Cardioversion, AF 24 h or more or unknown onset: 3 weeks of therapeutic OAC or TOE first
- After cardioversion: OAC for at least 4 weeks (optional only if AF onset under 24 h and no stroke risk factors)
- Path rejoins step 16Shared downstream outcome
Guideline Source
2024 ESC Guidelines for the management of atrial fibrillation (Van Gelder et al.)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- DOAC doses differ between Australian PIs and ESC Table 11 (apixaban CrCl limit, dabigatran age); check the local PI
- Does not cover timing after acute stroke, anticoagulation with recent ACS or PCI, perioperative interruption, or reversal
- Drug interactions listed are examples only
- Excludes pregnancy and children
Contraindicated Populations
pediatricpregnancy
Applicable Regions
EUUSAU
AU: NHFA/CSANZ 2018 uses CHA2DS2-VA (OAC if 2 or more; consider if 1). Edoxaban is not on the ARTG. Apixaban AU PI: contraindicated if CrCl <25 mL/min. Dabigatran AU PI: 110 mg twice daily from age 75. Bioprosthetic valve or TAVI: dabigatran contraindicated (Pradaxa PI 4.3); apixaban and rivaroxaban not recommended (PI 4.4).
EU: ESC 2024: CHA2DS2-VA (sex not scored; max 8 points). OAC if 2 or more; consider if 1.
US: ACC/AHA/ACCP/HRS 2023 uses CHA2DS2-VASc (max 9): OAC recommended if 2 or more in men or 3 or more in women; reasonable if 1 (men) or 2 (women).
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the AF Anticoagulation Decision (ESC 2024)?
The AF Anticoagulation Decision (ESC 2024) is a management clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2024 ESC Guidelines for the management of atrial fibrillation (Van Gelder et al.).
What guideline is the AF Anticoagulation Decision (ESC 2024) based on?
This algorithm is based on 2024 ESC Guidelines for the management of atrial fibrillation (Van Gelder et al.) (DOI: 10.1093/eurheartj/ehae176).
What are the limitations of the AF Anticoagulation Decision (ESC 2024)?
Known limitations include: DOAC doses differ between Australian PIs and ESC Table 11 (apixaban CrCl limit, dabigatran age); check the local PI; Does not cover timing after acute stroke, anticoagulation with recent ACS or PCI, perioperative interruption, or reversal; Drug interactions listed are examples only; Excludes pregnancy and children. Individual patient factors may require deviation from these recommendations.
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