Fast Five Quiz: Clinical Management of Atrial Fibrillation

Sandeep K. Goyal, MD


March 13, 2023

Anticoagulation for nonvalvular AF is managed with one of the direct oral anticoagulant (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 before cardioversion and do not require a bridge from heparin or low-molecular weight heparin.

Advantages to treating AF with DOAC agents over warfarin include:

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

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

  • Lower risk for intracranial hemorrhage

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

Disadvantages to using DOAC agents over vitamin K antagonists include:

  • Because DOAC agents have a short half-life, strict patient adherence 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 for 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 before and after 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 intravenously as a bridge to warfarin, especially in patients with valvular AF.

Learn more about treatment options for nonvalvular AF.


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