Fast Five Quiz: Clinical Management of Atrial Fibrillation

Sandeep K. Goyal, MD


April 02, 2020

Anticoagulation for nonvalvular AF is managed with one of the DOAC agents. Currently available DOAC agents include factor Xa inhibitors (apixaban, edoxaban, or rivaroxaban) and the direct thrombin inhibitor dabigatran. DOAC agents can be initiated prior to cardioversion and do not require a bridge from heparin or low-molecular weight heparin.

Advantages to treating AF with DOAC agents over warfarin include:

  • Less drug-drug and diet interactions with non–vitamin K oral anticoagulant agents

  • Bridging anticoagulation therapy is unnecessary due to the rapid onset and offset of non–vitamin K oral anticoagulant agents

  • Lower risk of intracranial hemorrhage

  • Lower risk of thromboembolism (with twice daily apixaban and dabigatran 150 mg)

Disadvantages to using DOAC agents over vitamin K antagonists include:

  • Due to the short half-life of DOAC agents, strict patient compliance is essential to maintain adequate anticoagulation

  • Limited safety profile for patients with AF and severe kidney disease

  • Lack of data on use in patients with mechanical heart valve or valvular AF (increased risk of thromboembolic complications seen with direct thrombin inhibitor)

  • Lack of data for use in pregnant, lactating, and pediatric patients, and in patients with a history of stroke

  • Lack of blood tests to monitor for therapeutic or toxic effects

Multiple studies investigating the efficacy of the combination of aspirin 325 mg and clopidogrel 75 mg orally once daily showed higher prevalence of significant hemorrhage. Therefore, the combination is not a preferred regimen for patients with nonvalvular AF.

Cardioversion, a medical procedure to correct arrhythmia, is not an anticoagulation strategy for patients with nonvalvular AF. However, anticoagulation is imperative prior to and following cardioversion (pharmacologic or direct current) to prevent thromboembolism.

A twice-daily dose of 5000 U subcutaneous unfractionated heparin is not an appropriate anticoagulation therapy for patients with nonvalvular AF. Weight-based heparin is often administered IV as a bridge to warfarin, especially in patients with valvular AF.

Read more about treatments for nonvalvular AF.


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