New Diagnosis of Atrial Fibrillation in the ED: A focus on anticoagulation
1. Stroke Risk: Assess the patient’s risk of stroke to determine if the patient is a candidate for anticoagulation. Risk of stroke can be determined by using the CHA2DS2 VASc calculator . A link is provided on the tool bar to the right. The scoring system assigns a point value to different medical conditions for each patient. Once the points are assigned, the total point value is calculated which correlated to a specific percentage for annual stroke risk. The scoring system and corresponding stroke risk can be found below.
CHA2DS2 VASc scoring system
CHA2DS2 VASc annual stroke risk
2. Consideration of anticoagulation: The 2014 ACC/AHA/HRS guidelines recommend using the risk of stroke together with shared decision making with the patient taking into account patient values and preferences.
For patients who underwent cardioversion in the ED: These patients will need anticoagulation for 4 weeks post cardioversion. Each of three trials of novel anticoagulants had several hundred patients undergoing electric cardioversion on novel drugs with comparable outcome compared to warfarin so those agents would be reasonable options.
3. How to pick an anticoagulant: There are many patient specific considerations when thinking about which anticoagulant is best suited for each patient. The clinical tools link on the home page of the website reviews patient specific considerations regarding medical history characteristics. It is also always important to consider whether the patient will be able to afford the cost of the medication.
4. Arranging follow up after starting an anticoagulant in the ED: It is important to have the patient follow up in a timely way, we recommend within one week to review if the patient is tolerating the medication and able to obtain the medication. A provider visit will need to be scheduled within a month of being started on the medication.
5. If the patient missed a dose: No double dose should be taken to make up for missed individual doses. If the patient is on a bid dose, recommend taking the missed dose up until 6 hours after the scheduled intake. If the patient is out of that window, resume with next dose as scheduled, skipping the missed dose. If the patient is on a daily dosing, the patient should take the missed dose up until 12 hours after the missed dose. If that is not possible, the dose should be skipped and the patient should resume the medication at the next scheduled dose as normal.