Atrial Fibrillation (AF)

The 2023 ACC/AHA/ACCP/HRS AF Guideline supports validated stroke-risk assessment such as CHA₂DS₂-VASc. The ACC CardioSmart AFib Stroke and Bleeding Risk Calculator can support discussions. Reassess at least annually and after clinical changes, regardless of AF pattern or apparent rhythm-control success.

Female sex alone is not an indication. The 2024 ESC AF Guidelines use CHA₂DS₂-VA; follow the selected framework’s thresholds.

Direct oral anticoagulants (DOACs) are guideline-recommended over warfarin for eligible patients. Selection considers bleeding history, renal function, interactions, dosing preferences, and cost. Observational comparisons associate apixaban with less gastrointestinal (GI) bleeding than other DOACs and less major bleeding than rivaroxaban; head-to-head randomized evidence is lacking.

Warfarin remains standard for mechanical valves or moderate-or-greater mitral stenosis and appropriate when DOAC cost prevents sustained treatment. Patients may continue well-managed warfarin after discussing tradeoffs. Consider INR access, monitoring costs, interactions, and time in therapeutic range; the usual AF target is INR 2–3.

• Use labeled dosing:
  • Use renal function, age, weight, and interaction criteria. Avoid unsupported dose reductions; advanced kidney disease requires individualized selection.
• Address bleeding risks:
  • Address uncontrolled blood pressure, unnecessary antiplatelets/NSAIDs, alcohol, and bleeding sources. A bleeding score alone should not exclude anticoagulation.
• Review aspirin:
  • Aspirin does not substitute for anticoagulation.
  • Beyond 1 year after coronary revascularization, without prior stent thrombosis, anticoagulant monotherapy is generally recommended. Recent ACS/PCI needs a separate plan.

Percutaneous LAAO is an alternative for selected patients with nonvalvular AF. The 2023 ACC/AHA/ACCP/HRS AF Guideline supports it for moderate-to-high stroke risk with a nonreversible contraindication to long-term anticoagulation. It may also be considered for high bleeding risk, weighing procedural risk against the more extensive anticoagulation evidence. Treatable bleeding does not automatically preclude anticoagulation.

The 2025 SCAI/HRS Transcatheter LAAO Guidelines conditionally support anticoagulation or LAAO, considering bleeding history, elevated bleeding risk, and strong patient preference to avoid long-term anticoagulation. Selection includes anatomy, frailty, expected benefit, and follow-up capacity; LAAO may be inappropriate with less than 1 year of quality life expectancy.

Discuss procedural bleeding, pericardial effusion, and stroke alongside long-term benefits. Postimplant anticoagulation or dual antiplatelet therapy and imaging remain necessary; device-related thrombus may require anticoagulation, and residual leak management remains uncertain. LAAO does not treat AF or remove other anticoagulation indications. Surgical appendage exclusion generally supplements indicated anticoagulation; benefit without continued anticoagulation is uncertain.

Discuss early rhythm control, especially within the first year or with symptoms or HF. Rate control may accompany rhythm control or serve as the main strategy, according to clinical circumstances and patient preferences.

• Cardioversion:
  • For AF ≥48 hours or uncertain duration, use ≥3 weeks of therapeutic anticoagulation or imaging to exclude thrombus beforehand.
  • Continue anticoagulation ≥4 weeks afterward, then according to stroke risk. Shorter-duration AF still requires risk assessment.
• Catheter ablation:
  • Use uninterrupted warfarin or continuous/minimally interrupted DOAC therapy.
  • Continue anticoagulation ≥3 months afterward under U.S. guidance, then according to stroke risk.
• Other procedures:
  • Plan interruption and restart by agent, renal function, bleeding risk, and hemostasis. Most patients do not need heparin bridging; mechanical valves or recent stroke/TIA require separate assessment.
• Patient planning:
  • The VLN Procedure Playbook includes guidance, calendars, and worksheets for a clinician-approved stop/restart plan around scheduled procedures.

Assign responsibility for symptoms, rate/rhythm, renal function, anticoagulant safety, and refills. Provide clear interruption and restart instructions.