From the Guidelines
Anticoagulation (AC) is not typically required for a single episode of atrial fibrillation (AFib) lasting only 5 minutes, as the decision to start anticoagulation should be based on the overall stroke risk assessed using the CHA₂DS₂-VASc score, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. The 2024 ESC guidelines emphasize the importance of assessing the risk of thromboembolism using locally validated risk tools or the CHA2DS2-VA score, with reassessment at periodic intervals to assist in decisions on anticoagulant prescription 1. Key points to consider in the management of AFib include:
- Assessing the risk of thromboembolism using the CHA2DS2-VA score
- Recommending anticoagulation for all eligible patients, except those at low risk of incident stroke or thromboembolism (CHA2DS2-VA = 1 anticoagulation should be considered; CHA2DS2-VA ≥2 anticoagulation recommended) 1
- Preferring direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) unless the patient has mechanical heart valves and mitral stenosis 1
- Managing modifiable bleeding risk factors to improve safety, and not using bleeding risk scores to decide on starting or withdrawing anticoagulants 1 It is essential to document the AFib episode and follow up with a healthcare provider who can properly evaluate the specific situation, determine if this was truly AFib, assess the stroke risk, and recommend appropriate monitoring or treatment.
From the Research
Atrial Fibrillation and Anticoagulation Therapy
- Atrial fibrillation (AF) substantially increases the risk of stroke and other thromboembolic events, making antithrombotic prophylaxis necessary for most AF patients 2.
- Oral anticoagulation (OAC) with either vitamin K antagonists (VKAs) or non-VKA oral anticoagulants can be used for this purpose unless contraindicated 2, 3.
- The risk of stroke and bleeding must be weighed individually, and risk assessment is an obligatory part of AF management 2, 4.
Duration of Atrial Fibrillation Episodes and Thromboembolic Risk
- The duration of an atrial fibrillation event that is long enough to increase the risk of embolic phenomena is not well established, but a burden of 5 minutes in one day has been shown to be independently associated with a significantly increased risk 5.
- The formation of an intracardiac thrombus and respective embolic potential is a dynamic process resulting from the interaction of anatomical and functional variables, and individual risk will depend on these factors 5.
- A standardized way to select patients with short-duration atrial fibrillation periods that will have a meaningful benefit of chronic oral anticoagulation is still to be defined, and decisions should be made in an individualized manner 5.
Anticoagulation Therapy for Atrial Fibrillation
- Anticoagulation has been the mainstay for prevention and treatment of thrombi and stroke in atrial fibrillation, with options including warfarin, aspirin, and direct oral anticoagulants (DOACs) such as dabigatran, rivaroxaban, and apixaban 3, 4.
- DOACs have demonstrated a dramatic reduction in the rate of intracranial hemorrhage compared to warfarin and offer the advantages of no monitoring and a lower risk of hemorrhages 3.
- The choice of anticoagulation therapy should be individualized based on the patient's risk factors, comorbid conditions, and preferences 2, 6.