Assessing Stroke and Bleeding Risk in AFib
This consensus statement was written by leading experts in the area of stroke prevention in atrial fibrillation (AFib). The consensus development was spearheaded by the Atrial Fibrillation Optimal Treatment Task Force, led by the Alliance for Aging Research. The resulting statement provides a standardized approach to assessing moderate- to high-risk patients and determining who should be on an anticoagulant medication. Additionally, the document presents the leading stroke and bleeding risk tools all in one place--making them easy for health care professionals to access and compare.Read the full consensus statement by clicking on the image below:
Consensus Recommendations
The primary objective of the AFib Optimal Treatment Task Force was to reduce the burden of stroke in AFib by creating consensus on the best practices for assessing stroke and bleeding risk in anticoagulation decision-making. The Task Force convened a roundtable of leading experts in cardiology, neurology, anticoagulants, and more to address this challenge and develop a consensus statement.
The consensus statement provides guidance on: (1) The process for assessing risk and making anticoagulant decisions in AFib; (2) Making decisions on anticoagulants in a landscape with increasing options; and (3) Promising areas of research requiring additional investigation.
Although anticoagulation is very effective at reducing AFib-related strokes, studies show that it is underused. AFib is more common in older adults, who are often regarded by their physicians as frail or at risk of falls. The Edge Research team revealed that when considering bleeding risk, fall risk tops the list of factors that they feel should be considered. This underuse of anticoagulants in older patients – those at heightened risk of stroke from AFib – is a major obstacle to effective care that reduces morbidity and mortality.
In the consensus statement, the experts recommend a three-step approach to anticoagulation decision-making in patients with AFib:
- First, a patient’s stroke risk should be assessed and recorded no less than annually using an established scoring tool. Those identified as intermediate or high risk should be put on an anticoagulant – warfarin or a direct thrombin inhibitor or a factor Xa inhibitor. Aspirin is not recommended for stroke prophylaxis in AFib.
- Second, if the patient is at high enough risk to require anticoagulation therapy, the patient’s bleeding risk should then be evaluated to estimate the net clinical benefit of an anticoagulant, again using an available tool as a starting point. Risk factors for intracranial hemorrhage should be considered although routine screening for these risk factors is not currently indicated.
For the majority of patients, the net benefit of stroke prophylaxis supersedes the “net harm” of serious bleeding events – even in older patients. The experts also emphasized that assessment of bleeding risk is not an opportunity to look for reasons not to anticoagulate, but an opportunity to address correctable risk factors for bleeding. - Third, the decision to undergo anticoagulation therapy must reflect patient preferences and values. The patient must also understand the relative benefits and risks and be involved in the discussion and ultimate decision surrounding the clinical net benefit of anticoagulation therapy.
Finally, the consensus experts called for enhanced patient education materials, tools, and outreach. Many patients are not aware that AFib confers a five-fold increase in stroke risk and participants recommended initiatives that prompt conversations about stroke risk between patients and medical providers. The task force also suggested that organizations join forces to promote accurate and objective healthcare information with a consistent message and voice.
Download the consensus document here