AFib Anticoagulation Decision (ESC 2024)

Algorithm Steps

1. ▶

   Start

   AFib - Anticoagulation Decision

   Non-valvular atrial fibrillation

   1. ◆

      Decision

      Valvular AFib?

      Mechanical valve or mod-severe MS

      If Yes:

      1. ⚠

         Warning

         WARFARIN ONLY

         DOACs contraindicated

         • Mechanical heart valve
         • Moderate-severe mitral stenosis
         • Target INR per valve type

      If No:

      1. ●

         Action

         Calculate Stroke Risk

         CHA₂DS₂-VA (ESC) or VASc (ACC)

         • C: CHF (+1)
         • H: Hypertension (+1)
         • A₂: Age ≥75 (+2)
         • D: Diabetes (+1)
         • S₂: Stroke/TIA (+2)
         • V: Vascular disease (+1)
         • A: Age 65-74 (+1)
         • ESC 2024: Sex no longer scored
         1. ◆

            Decision

            Score Result?

            1. ●

               Action

               Score ≥2: Anticoagulate

               Class I recommendation

               • DOAC preferred over warfarin
               • Strong recommendation
               1. ●

                  Action

                  DOAC Selection

                  Choose based on patient factors

                  • Apixaban: Best safety profile, renal flexibility
                  • Rivaroxaban: Once daily, with food
                  • Edoxaban: After 5-day parenteral
                  • Dabigatran: Reversible, GI side effects
                  1. ●

                     Action

                     HAS-BLED Assessment

                     Identify modifiable bleeding risks

                     • NOT to withhold anticoagulation
                     • Modify: HTN, labile INR, drugs, alcohol
                     • Score ≥3 = high bleeding risk - optimize factors
                     1. ✓

                        Outcome

                        Anticoagulation Initiated

                        Monitor, reassess annually

            2. ●

               Action

               Score 1: Consider OAC

               Class IIa - Shared decision

               • Discuss risk/benefit
               • Individual factors matter
               • Lean toward anticoagulation
            3. ●

               Action

               Score 0: No OAC

               Not recommended

               • Reassess if risk factors develop
               • Annual stroke risk <1%