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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Anticoagulation in cardiovascular disease

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Major bleeding, suspected intracranial haemorrhage, acute embolic stroke or thrombosed mechanical valve requires immediate emergency assessment; record the exact anticoagulant, dose and last ingestion while resuscitation proceeds.

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.
  • Do not substitute aspirin for anticoagulation in AF stroke prevention.
  • Do not withhold anticoagulation solely because of age or falls risk.
  • Dose DOACs using Cockcroft-Gault creatinine clearance, not laboratory eGFR alone.
  • Review renal function, adherence, interacting medicines and bleeding regularly; DOACs do not require routine INR monitoring.

Key red flags

Acute embolism

Sudden focal neurology, painful pulseless limb or visceral ischaemia may represent embolism despite or without treatment.

Major bleeding

Haemodynamic instability, intracranial features, ongoing GI bleeding or a substantial haemoglobin fall needs urgent reversal planning.

Investigation priorities

01
12-lead ECG or ambulatory ECGFirst step

Document AF/flutter and define rhythm burden when intermittent.

Management branches

FirstAF stroke prevention

Confirmed AF or atrial flutter.

  1. Confirm the rhythm and identify mechanical valves, rheumatic mitral stenosis and reversible precipitants.
  2. Calculate CHA2DS2-VASc and ORBIT; correct blood pressure, anaemia, renal impairment, alcohol excess and interacting medicines where possible.
  3. Offer a DOAC when indicated and eligible, using Cockcroft-Gault CrCl and the product-specific reduction criteria.
  4. If a vitamin K antagonist is required, state the target INR and establish anticoagulation-clinic follow-up.

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.Active bleeding, severe hepatic disease, strong dual CYP3A4/P-gp interactions and renal impairment; not for mechanical valves.
RivaroxabanNon-valvular AF: 20 mg orally once daily with food; 15 mg once daily with food when CrCl is 15 to 49 mL/min.Use Cockcroft-Gault CrCl; avoid at CrCl below 15 mL/min and in mechanical valves. Strong CYP3A4/P-gp interactions and missed doses are important.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG196: Atrial fibrillationStroke/bleeding assessment, DOAC choice and review.
  • MHRA: DOAC bleeding risk and reversal agentsRenal dosing, bleeding precautions and reversal.
  • MHRA: renal-function estimates for medicinesCockcroft-Gault for DOAC dosing.
  • Apixaban 5 mg SmPCAF dosing and reduction criteria.
  • Rivaroxaban SmPCAF and VTE dosing.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom