Last updated March 15, 2022

Prevention Of Stroke In Nonvalvular Atrial Fibrillation

Treatment

Warfarin (A)
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dabigatran (B)
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apixaban (B)
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rivaroxaban (B)
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The safety and efficacy of combining dabigatran, rivaroxaban, or apixaban with an antiplatelet agent have not been established. (C)
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Aspirin, Clopidogrel & Warfarin

Adjusted-dose warfarin (target INR – 2.0-3.0) is recommended for all patients with nonvalvular AF deemed to be at high risk and many deemed to be at moderate risk for stroke who can receive it safely. (A)
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Antiplatelet therapy with aspirin is recommended for low-risk and some moderate-risk patients with AF on the basis of patient preference, estimated bleeding risk if anticoagulated, and access to high-quality anticoagulation monitoring. (A)
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For high-risk patients with AF deemed unsuitable for anticoagulation, dual-antiplatelet therapy with clopidogrel and aspirin offers more protection against stroke than aspirin alone, but with an increased risk of major bleeding, and might be reasonable. (B)
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For patients with ischemic stroke or TIA with paroxysmal (intermittent) or permanent AF, anticoagulation with a vitamin K antagonist (target INR – 2.5; range – 2.0-3.0) is recommended. (A)
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For patients unable to take oral anticoagulants, aspirin alone is recommended. (A)
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The combination of clopidogrel plus aspirin carries a risk of bleeding similar to that of warfarin and therefore is NOT recommended for patients with a hemorrhagic contraindication to warfarin. (B)
(III)
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Dabigatran

Dabigatran is useful as an alternative to warfarin for the prevention of stroke and systemic thromboembolism in patients with paroxysmal to permanent AF and risk factors for stroke or systemic embolization who do not have a prosthetic heart valve or hemodynamically significant valve disease, severe renal failure (CrCI <15 mL/min), or advanced liver disease (impaired baseline clotting function). (B)
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Dabigatran 150 mg twice daily is an efficacious alternative to warfarin for the prevention of first and recurrent stroke in patients with nonvalvular AF and at least one additional risk factor who have CrCI >30 mL/min. (B)
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On the basis of pharmacokinetic data, the use of dabigatran 75 mg twice daily in patients with AF and at least one additional risk factor who have a low CrCI (15-30 mL/min) may be considered, but its safety and efficacy have not been established. (C)
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Because there are no data to support the use of dabigatran in patients with more severe renal failure, dabigatran is NOT recommended in patients with a CrCI <15 mL/min. (C)
(III)
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Apixaban

Apixaban 5 mg twice daily is an efficacious alternative to aspirin in patients with nonvalvular AF deemed unsuitable for vitamin K antagonist therapy who have at least one additional risk factor and no more than one of the following characteristics: Age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. (B)
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Although its safety and efficacy have not been established, apixaban 2.5 mg twice daily may be considered as an alternative to aspirin in patients with nonvalvular AF deemed unsuitable for vitamin K antagonist therapy who have at least 1 additional risk factor and ≥2 of the following criteria: Age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. (C)
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Apixaban 5 mg twice daily is a relatively safe and efficacious alternative to warfarin in patients with nonvalvular AF deemed appropriate for vitamin K antagonist therapy who have at least one additional risk factor and no more than one of the following characteristics: Age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. (B)
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Although its safety and efficacy have not been established, apixaban 2.5 mg twice daily may be considered as an alternative to warfarin in patients with nonvalvular AF deemed appropriate for vitamin K antagonist therapy who have at least 1 additional risk factor and ≥2 of the following criteria: Age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. (C)
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Apixaban should NOT be used if the CrCI is <25 mL/min. (C)
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Rivaroxaban

In patients with nonvalvular AF who are at moderate to high risk of stroke (prior history of TIA, stroke, or systemic embolization or ≥2 additional risk factors), rivaroxaban 20 mg/d is reasonable as an alternative to warfarin. (B)
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In patients with renal impairment and nonvalvular AF who are at moderate to high risk of stroke (prior history of TIA, stroke, or systemic embolization or ≥2 additional risk factors), with a CrCI of 15 to 50 mL/min, 15 mg of rivaroxaban daily may be considered. However, its safety and efficacy have not been established. (C)
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Rivaroxaban should NOT be used if the CrCI is <15 mL/min. (C)
(III)
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Recommendation Grading

Overview

Title

Prevention Of Stroke In Nonvalvular Atrial Fibrillation

Authoring Organization

Endorsing Organization

Publication Month/Year

February 24, 2014

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To update the 1998 American Academy of Neurology practice parameter on stroke prevention in nonvalvular atrial fibrillation (NVAF).

Inclusion Criteria

Male, Female, Adult

Health Care Settings

Emergency care, Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Prevention

Diseases/Conditions (MeSH)

D001281 - Atrial Fibrillation

Keywords

atrial fibrillation, chronic kidney disease, echocardiography, gastrointestinal

Source Citation

Summary of evidence-based guideline update: Prevention of stroke in nonvalvular atrial fibrillation Report of the Guideline Development Subcommittee of the American Academy of Neurology Antonio Culebras, Steven R. Messé, Seemant Chaturvedi, Carlos S. Kase, Gary Gronseth Neurology Feb 2014, 82 (8) 716-724; DOI: 10.1212/WNL.0000000000000145