From the Guidelines
The next best step for treatment of this 58-year-old male with newly developed atrial fibrillation during hospitalization for spontaneous bacterial peritonitis (SBP), who also has cirrhosis and coronary artery disease with history of NSTEMI and PCI, is to risk assess for anticoagulation. This patient has multiple comorbidities that increase both his stroke risk and bleeding risk, making a careful assessment of the risks and benefits of anticoagulation essential. The risk assessment should include calculating his CHA₂DS₂-VASc score to determine stroke risk and his HAS-BLED score to evaluate bleeding risk, with particular attention to his cirrhosis which significantly increases bleeding concerns, as noted in the AGA clinical practice guideline on the management of coagulation disorders in patients with cirrhosis 1. This evaluation should be done during the current hospitalization rather than deferring to outpatient follow-up, as decisions about rate control, rhythm control, and anticoagulation need to be made before discharge. Key considerations include:
- Calculating the CHA₂DS₂-VASc score to assess stroke risk
- Evaluating the HAS-BLED score to assess bleeding risk
- Considering the impact of cirrhosis on coagulation and bleeding risk, as discussed in the AGA technical review on coagulation in cirrhosis 1
- Weighing the benefits of anticoagulation against the risks, particularly in the context of cirrhosis and a history of coronary artery disease and PCI, as guided by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. The patient's cirrhosis complicates anticoagulation decisions, as it may cause coagulopathy and increase the risk of variceal bleeding, requiring careful consideration of whether the stroke prevention benefits outweigh the heightened bleeding risks in this specific case.
From the FDA Drug Label
The trials in non-valvular atrial fibrillation support the American College of Chest Physicians’ (7th ACCP) recommendation that an INR of 2.0-3.0 be used for warfarin therapy in appropriate AF patients. Oral anticoagulation therapy with warfarin is recommended in patients with persistent or paroxysmal AF (PAF) (intermittent AF) at high risk of stroke (i.e., having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age >75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus)
The next best step for treatment of this patient is to Risk assess for anticoagulation. This patient has a history of CAD with NSTEMI, PCI, and cirrhosis, and has developed atrial fibrillation, which puts him at high risk of stroke. Therefore, assessing the risk of anticoagulation is crucial to determine the best course of treatment. 2
From the Research
Next Best Step for Treatment
The next best step for treatment of this patient with atrial fibrillation is to:
Rationale
The patient has a history of cirrhosis, CAD with history of NSTEMI, PCI, and has developed atrial fibrillation during admission for SBP.
- The CHA2DS2-VASc score is used to predict the risk of thromboembolism in patients with atrial fibrillation 3, 4, 5
- The HAS-BLED score is used to assess the risk of bleeding in patients with atrial fibrillation who are taking oral anticoagulants 3, 4, 7
- Anticoagulation therapy is recommended for preventing stroke in persons with atrial fibrillation, and direct oral anticoagulants are first-line agents for eligible patients 6, 7
- Validated bleeding risk assessments such as HAS-BLED should be performed at each visit and modifiable factors should be addressed 7
Considerations
- The patient's history of cirrhosis and CAD may increase the risk of bleeding and thrombosis
- The patient's development of atrial fibrillation during admission for SBP may indicate a need for anticoagulation therapy
- The choice of anticoagulant will depend on the patient's individual risk factors and medical history 3, 4, 5, 6, 7