e16

An important misconception about warfarin is that if

anticoagulated patients bleed, the risk can be quickly
reversed, but most trial experience has found that warfarin
reversal requires 24 hours to halve the INR value. Reversal
of anticoagulation with the NOACs is unproven at present;
possible approaches are presented in this review, but since
the NOACs have both rapid onsets of action and short
biologic half-lives, they do not present the same reversal
challenges as warfarin. Finally, physicians must be aware
of thromboembolic risk assessment. The principal risk
assessment scores are CHADS2, updated with the more
recent CHA2DS2-VASc to provide more accurate assessment of low-risk patients; this review concludes with a
novel ow-chart showing physicians how the CHADS2/
CHA2DS2-VASc scoring systems can be used.
2014 Published by Elsevier Inc.
The American Journal
of Medicine (2014) 127, e15-e16

AUTHOR DISCLOSURES
James A. Reiffel, MD, has disclosed the following relevant
nancial relationships:
Served as an advisor or consultant for: sano-aventis;
Gilead Sciences, Inc.; CV Therapeutics; GlaxoSmithKline;
Merck & Co., Inc.; Cardiome Pharma Corp.; Boehringer
Ingelheim Pharmaceuticals, Inc.; Medtronic, Inc. Served as a
speaker or a member of a speakers bureau for: sano-aventis;
Boehringer Ingelheim Pharmaceuticals, Inc.
Received grants for clinical research from: Boehringer
Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline. Dr. Reiffel
does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in
the United States.

AFib Treatment: General Population

Steven A. Rothman, MD
Lankenau Medical Center, Lankenau Institute for Medical
Research, Wynnewood, Pennsylvania.

ABSTRACT
When primary care physicians are presented with a patient
with atrial brillation (AFib), there are two concerns. (online
video available at: http://education.amjmed.com/video.php?
event_id445&stage_id5&vcs1). One is the choice of
strategy to treat the AFib, ie, whether to use rate control or a
rhythm control strategy (to keep patients in sinus rhythm).
The second concern is preventing the principal risk associated
with AFib: stroke and systemic embolism. The focus of this
review is stroke prevention, concentrating on risk assessment
and traditional versus the new oral anticoagulation agents.
For the past several decades, oral anticoagulation therapy has
meant warfarin, which has the benet of >50 years of clinical
experience: it is inexpensive, it has generic availability, and it

The American Journal of Medicine, Vol 127, No 4, April 2014

has a wide range of clinical use indications beyond merely
stroke prophylaxis in patients with AFib. On the other hand,
only about half of the patients who should be receiving warfarin
are prescribed it (and even fewer older patients are prescribed
it), and only 30% of patients maintain time in therapeutic
range (TTR) for serum warfarin levels at or above INR 2e3.
According to a recent survey, almost a quarter of physicians
employ rhythm control to treat AFib, and many of these believe
that rhythm control decreases stroke and mortality risk sufciently that anticoagulation therapy is not necessary. In addition, many physicians believe that when AFib is paroxysmal
as opposed to permanent, then risk of stroke is low enough
that long-term anticoagulation is not necessary. As discussed
in this review, however, neither of these beliefs is true.
Regarding bleeding risk, the same survey found that physicians
perceive the risks of anticoagulation to be far greater than the
benets. Again, the evidence reveals that the patients at
highest risk of bleeding are also at highest risk of stroke, and
the benets of preventing stroke with anticoagulation therapy
almost always outweigh the risk of bleeding. This is discussed
in the context of the new NOACs (discussed in the next review), including addressing what physicians should do if
patients move from warfarin to one of the NOACs or vice
versa. A nal challenge for physicians treating patients with
AFib has been the often mistaken belief that patients are at a
low-risk status, and this review concludes with an overview of
the use of the CHADS2 versus the CHA2DS2-VASc risk
scoring systems, including why CHA2DS2-VASc provides a
better assessment of which patients are or are not at low risk.
2014 Published by Elsevier Inc.
The American Journal
of Medicine (2014) 127, e16

AUTHOR DISCLOSURES
Dr. Rothman is a consultant or has participated in a
Speakers Bureau for Astra-Zeneca, sano-aventis, Boehringer Ingelheim, Boston Scientic, and St. Jude Medical.

Novel Oral Anticoagulants

James A. Reiffel, MD
Department of Medicine, Columbia University, New York,
New York.

ABSTRACT
Warfarin has a proven record as an oral anticoagulant;
almost every study, however, has found that it is not prescribed for 40e60% of patients who are eligible and should
receive it, and of those who do receive it, serum warfarin
levels only achieved a time in therapeutic range (TTR)
equal to INR 2e3 about 55e60% of the time (online video
available at: http://education.amjmed.com/video.php?event_
id445&stage_id5&vcs1). This means that only about