What are the absolute contraindications to anticoagulation in patients with a high CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, Stroke or transient ischemic attack, Vascular disease, Age 65-74 years, Sex category) score?

Absolute Contraindications to Anticoagulation in Patients with High CHA₂DS₂-VASc Score

Patients with high CHA₂DS₂-VASc scores should not receive anticoagulation if they have active major bleeding, severe uncontrolled hypertension, or a history of intracranial hemorrhage with high risk of recurrence. 1

Major Absolute Contraindications

• Active major bleeding: Ongoing significant hemorrhage that requires medical intervention represents an absolute contraindication to anticoagulation 1
• Recent or planned major surgery/procedure with high bleeding risk: Procedures with significant risk of hemorrhagic complications 1
• Severe uncontrolled hypertension: Particularly when blood pressure consistently exceeds 180/120 mmHg, as this significantly increases bleeding risk 1
• History of intracranial hemorrhage with high risk of recurrence or severe sequelae 1
• End-stage liver disease with coagulopathy and elevated bleeding risk 1
• Severe thrombocytopenia (platelet count <50,000/μL) 1
• Hypersensitivity or allergy to all available anticoagulant medications 1

Relative Contraindications (Requiring Risk-Benefit Assessment)

• Recent non-major bleeding: Requires evaluation of bleeding source and risk of recurrence 1
• High risk of falls: Particularly in elderly patients with history of traumatic falls 1
• Cognitive impairment with inability to comply with medication regimen and without adequate caregiver support 1
• Chronic alcohol abuse with high risk of non-compliance and traumatic injury 1
• Concurrent use of dual antiplatelet therapy: Significantly increases bleeding risk when combined with anticoagulation 2
• Severe renal impairment: May require dose adjustment or alternative anticoagulation strategies rather than complete avoidance 3

Risk Assessment Approach

When evaluating patients with high CHA₂DS₂-VASc scores:

1. Calculate bleeding risk using validated tools such as HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history, labile INR, elderly, drugs/alcohol) 1
2. Balance stroke risk against bleeding risk: The higher the CHA₂DS₂-VASc score, the greater the potential benefit of anticoagulation despite bleeding risks 1
3. Consider alternative approaches for patients with absolute contraindications:
   • Left atrial appendage closure/occlusion devices 1
   • Temporary IVC filters (for venous thromboembolism) 1

Important Considerations

• The fear of falls may be overstated in clinical practice—a patient would need to fall approximately 300 times per year for the risk of intracranial hemorrhage to outweigh the benefit of anticoagulation in stroke prevention 1
• High bleeding risk alone should not automatically exclude patients from anticoagulation, especially those with very high CHA₂DS₂-VASc scores (≥4) where the absolute benefit is substantial 4
• For patients with temporary contraindications, anticoagulation should be reconsidered once the contraindication resolves 1
• Antiplatelet therapy is not recommended as an alternative to anticoagulation for stroke prevention in AF patients with high CHA₂DS₂-VASc scores 1

Special Situations

• Post-bleeding management: For patients with high thrombotic risk who experienced bleeding, consider resuming anticoagulation after bleeding is controlled, potentially with lower doses or alternative agents 1
• Perioperative management: Temporary interruption of anticoagulation may be necessary, with bridging therapy considered for those at highest risk 1
• Mechanical heart valves: Warfarin remains the only indicated anticoagulant; DOACs are contraindicated 3

Remember that while these contraindications are important, the decision to withhold anticoagulation in a patient with high CHA₂DS₂-VASc score should be carefully considered, as the stroke risk is substantial and often outweighs bleeding concerns in most patients.