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Thromboembolic Prophylaxis in Atrial Fibrillation

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    Overview and Recommendations

    • Background

    • Evaluation

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      Management

      • Treatment Based on Risk

      • Type of Anticoagulant Therapy

      • Left Atrial Appendage Closure

      • Reversal of Anticoagulation for Patients with Life-Threatening Bleeding

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        Interruption of Anticoagulation for Patients with Atrial Fibrillation During Procedures

        • Before and After Surgical Procedures

        • Before and After Cardioversion for Atrial Fibrillation

  • Related Summaries

  • Overview

  • Definitions

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    Recommendations

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      American College of Chest Physicians (ACCP) guideline on antithrombotic therapy for atrial fibrillation

      • Recommendations

      • Algorithms

    • American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines

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      Canadian Cardiovascular Society (CCS) guideline

      • Recommendations

      • Algorithm

    • European Society of Cardiology (ESC) guideline

    • American Heart Association/American Stroke Association (AHA/ASA) guidelines

    • National Institute for Health and Care Excellence (NICE) guideline

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    Assessing Embolic and Bleeding Risk

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      Assessing risk for stroke (ischemic and hemorrhagic) and thromboembolism

      • Background and recommendations from professional organizations

      • CHA2DS2-VASc risk score

      • CHADS2 risk score (original and modified)

      • ATRIA score

      • ABC-Stroke risk score

      • Evidence comparing stroke risk scores

      • Risk factors for stroke

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      Assessing bleeding risk

      • Background and recommendations from professional organizations

      • HAS-BLED score

      • ORBIT score

      • ATRIA score

      • ABC-Bleeding risk score

      • Other bleeding risk scores

      • Evidence comparing bleeding risk scores

    • Assessing composite of embolic and bleeding risk

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    Risk-Based Approach to Antithrombotic Therapy

    • Indications for anticoagulant therapy

    • Selecting anticoagulant agent when anticoagulant therapy indicated

    • Antithrombotic therapy in patients with atrial fibrillation and coronary artery disease (indications for double/triple therapy and selecting antithrombotic agents)

    • Evidence for triple therapy in patients with atrial fibrillation and coronary artery disease

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    Vitamin K Antagonists (VKAs)

    • Background and recommendations

    • Efficacy (vs. no anticoagulant)

    • Comparative efficacy vs. antiplatelet therapy

    • Comparative efficacy vs. direct oral anticoagulants (DOACs)

    • Stroke and bleeding rates on warfarin (noncomparative data)

    • Target INR

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    Direct Oral Anticoagulants (DOACs)

    • Background and recommendations

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      Direct thrombin inhibitors (dabigatran)

      • Recommendations and drug dosing

      • Efficacy (vs. no anticoagulant)

      • Comparative efficacy vs. VKA therapy

      • Efficacy comparing dabigatran doses

      • Adverse effects

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      Factor Xa inhibitors

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        Rivaroxaban

        • Recommendations and drug dosing

        • Comparative efficacy vs. VKA therapy

        • Efficacy comparing rivaroxaban doses

        • Adverse effects

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        Apixaban

        • Recommendations and drug dosing

        • Comparative efficacy vs. VKA therapy

        • Comparative efficacy vs. aspirin

        • Comparative efficacy vs. other anticoagulants in patients with kidney disease

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        Edoxaban

        • Recommendations and drug dosing

        • Comparative efficacy vs. VKA therapy

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      Comparative efficacy vs. VKA therapy

      • Comparative efficacy vs. VKA therapy for standard DOAC doses in general/mixed population of patients with atrial fibrillation

      • Comparative efficacy vs. VKA therapy in patients with newly diagnosed atrial fibrillation

      • Comparative efficacy vs. VKA therapy in patients with chronic kidney disease

      • Comparative efficacy vs. VKA therapy in older adults

      • Comparative efficacy vs. VKA therapy in patients on concurrent aspirin therapy

      • Comparative efficacy vs. VKA therapy for low- or high-dose DOACs

    • Comparative efficacy (among direct oral anticoagulants [DOACs])

    • Comparative evidence for adverse events among direct oral anticoagulants (DOACs)

    • Evidence for drug adherence

    • Adverse effects of concomitant use with other drugs

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    Antiplatelet Therapy

    • Background and recommendations

    • Efficacy of aspirin (vs. no antithrombotic therapy)

    • Comparative efficacy of clopidogrel plus aspirin vs. aspirin

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      Comparative efficacy of antiplatelets or clopidogrel plus antiplatelet vs. anticoagulation

      • Antiplatelets vs. anticoagulation

      • Aspirin vs. warfarin

      • Clopidogrel plus aspirin vs. warfarin

  • Anticoagulant plus Antiplatelet

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    Left Atrial Appendage Closure

    • Background and recommendations

    • Comparative efficacy vs. anticoagulant therapy

    • Efficacy in patients undergoing cardiac surgery (vs. no left atrial appendage closure)

    • Device complications

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    Thromboembolic Prophylaxis For Patients Undergoing Cardioversion

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      Recommendations from Professional organizations

      • American College of Chest Physicians (ACCP)

      • American College of Cardiology/American Heart Association (ACC/AHA)

      • Canadian Cardiovascular Society (CCS)

      • European Society of Cardiology (ESC)

    • Efficacy comparing anticoagulant agents

    • Efficacy for transesophageal echocardiogram (TEE)-guided approach

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    Adverse Effects of Thromboembolic Prophylaxis

    • Bleeding or stroke

    • Gastrointestinal adverse effects

    • Other adverse effects

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    Quality Improvement

    • Physician Quality Reporting System Quality Measures

    • Quality and Outcomes Framework Indicators

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    Guidelines and Resources

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      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Australian and New Zealand guidelines

    • Review articles

    • MEDLINE search

  • Patient Decision Aids

  • Patient Information

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    ICD Codes

    • ICD-10 codes

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    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editors
Panagiotis Papageorgiou MD, PhD
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Affiliations

Assistant Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Papageorgeiou declares no relevant financial conflicts of interest.

Topic Editors
Laurence Epstein MD, FACC
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Affiliations

Professor of Medicine, Harvard Medical School; Massachusetts, United States; Chief of Arrhythmia Service, Brigham and Women's Hospital; Massachusetts, United States

Conflicts of Interest

Dr. Epstein declares relevant financial relationships with Spectranetics (Speaker), Medtronic, Boston Scientific, and St. Jude (Speaker/Consultant).

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP
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Affiliations

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Peter Oettgen MD
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Affiliations

Editor in Chief, DynaMed; Cardiologist, Beth Israel Deaconess Medical Center; Massachusetts, United States; Associate Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Oettgen declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians
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