HealthDay News — Updated guidelines for managing atrial fibrillation from the American College of Cardiology and the American Heart Association include recommendations for recently approved oral anticoagulants.

The guidelines now recommend dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) alongside warfarin for patients with nonvalvular AF who have a history of stroke or transient ischemic attack or an otherwise elevated risk for stroke.

For patients with AF who have mechanical heart valves, the guidelines recommend warfarin, with target INR intensity (2.0 to 3.0 or 2.5 to 3.5) based on prosthesis type and location.

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For patients who cannot maintain a therapeutic INR between 2.0 and 3.0 on warfarin, clinicians should consider using one of the newer anticoagulants, committee chair Craig T. January, MD, PhD, from the University of Wisconsin-Madison, and colleagues, recommend.

The new AF guidelines replace the last full document on the topic from 2006 and two focused updates issued in 2011.

Some of the recently approved anticoagulants should not be used in certain patients, according to the recommendations. Dabigatran is contraindicated in patients with mechanical heart valves, and neither dabigatran nor rivaroxaban should be used to treat patients with end-stage chronic kidney disease, or who are on hemodialysis, due to a lack of randomized trial evidence on safety and efficacy in these populations.

“The selection of an antithrombotic agent should be based on shared decision-making that takes into account risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in INR therapeutic range if the patient has been on warfarin, irrespective of whether the atrial fibrillation pattern is paroxysmal, persistent, or permanent,” the authors wrote.

Other major changes in the updated recommendations include:

  • Use of the more comprehensive CHA2DS2-VASc score to assess stroke risk, instead of the older CHADS2 score
  • A reduced role for aspirin, as data indicating that aspirin diminishes stroke risk are weak
  • Greater use of radio frequency ablation for treating nonvalvular AF

The authors called for more research on new drug therapies, such as antiarrhythmic drugs with atrial selectivity and drugs to tackle fibrosis.

“The successful introduction of new anticoagulants is encouraging and further investigations will better inform clinical practices for optimizing beneficial applications and minimizing the risks of these agents, particularly in the elderly, in the presence of comorbidities and in the periprocedural period,” the authors wrote.

The guidelines will be available online in the Journal of the American College of Cardiology, Circulation and Heart Rhythm.


  1. January CT et al. J Am Coll Cardiol. 2014; doi:10.1016/j.jacc.2014.03.021.

Disclosures: Several authors and reviewers disclosed financial ties to the pharmaceutical and medical device industries.