Synopsis
Use oral anticoagulation safely for cardiovascular thromboembolism prevention, especially atrial fibrillation, cardioversion and mechanical valves.
- Use CHA2DS2-VASc to assess AF-related stroke risk and ORBIT to identify modifiable bleeding risk; a bleeding score is not an automatic reason to withhold treatment.
- Offer a DOAC first line for eligible non-valvular AF when anticoagulation is indicated.
- Do not use a DOAC for a mechanical prosthetic valve; use a vitamin K antagonist with the valve-specific INR target.
Key red flags
Sudden focal neurology, painful pulseless limb or visceral ischaemia may represent embolism despite or without treatment.
Investigation priorities
Document AF/flutter and define rhythm burden when intermittent.
Management branches
Confirmed AF or atrial flutter.
- Confirm the rhythm and identify mechanical valves, rheumatic mitral stenosis and reversible precipitants.
- Calculate CHA2DS2-VASc and ORBIT; correct blood pressure, anaemia, renal impairment, alcohol excess and interacting medicines where possible.
Key medicines
ApixabanNon-valvular AF: 5 mg orally twice daily; reduce to 2.5 mg twice daily when at least 2 apply: age 80 years or older, weight 60 kg or less, serum creatinine 133 micromol/L or more. Use 2.5 mg twice daily for CrCl 15 to 29 mL/min in AF.
RivaroxabanNon-valvular AF: 20 mg orally once daily with food; 15 mg once daily with food when CrCl is 15 to 49 mL/min.