Selected Guideline Resources

• 2023 Atrial Fibrillation Guideline - Table 8: Three Validated Risk Models for Stroke
• 2023 Atrial Fibrillation Guideline - Table 9: Some Best Known Published Clinical Scores with Potential Advantages
• 2023 Atrial Fibrillation Guideline - Table 19: Recommended Doses of Currently Approved DOACs According to Renal Function

Patient Resources

• Atrial Fibrillation Patient Hub and Topic Center
• What is AFib? (infographic)
• Atrial Fibrillation and Lowering Stroke Risk (infographic)
• Your Action Plan for Managing Atrial Fibrillation
• CardioSmart Decision Aid Booklets and Videos:
  
  • Very high risk for stroke decision aid booklet and video
  • High risk for stroke decision aid booklet and video
  • Moderate risk for stroke decision aid booklet and video
  • Low risk for stroke decision aid booklet and video

Other Anticoagulation Resources

• ACC Anticoag Management Topic Collection
• ACC AFib Toolkit
• DOAC Dosing Infographic

Other Mobile Tools

• ACC’s Clinical App Collection

References

1. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation : Joglar, J, Chung, M. et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
   J Am Coll Cardiol. 2024 Jan, 83 (1) 109–279.

2. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: January C, Wann L, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation.
   J Am Coll Cardiol. 2019 Jul, 74 (1) 104–132.

3. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: January C, Wann L, Alpert J, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014 Dec, 64 (21) e1–e76.

4. CHA₂DS₂-VASc: Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010 Feb;137(2):263-72. doi: 10.1378/chest.09-1584. Epub 2009 Sep 17. PubMed PMID: 19762550.

5. HAS-BLED: Pisters R, Lane DA, Nieuwlaat R, et al. A Novel User-Friendly Score (HAS-BLED) To Assess 1-Year Risk Of Major Bleeding In Patients With Atrial Fibrillation: The Euro Heart Survey. Chest. 2010;138(5):1093-1100

6. Cockcroft-Gault Equation for CrCl: Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41. PubMed PMID: 1244564

7. A New Risk Scheme to Predict Ischemic Stroke and Other Thromboembolism in Atrial Fibrillation: The ATRIA Study Stroke Risk Score: Daniel E. Singer, Yuchiao Chang, Leila H. Borowsky, Margaret C. Fang, Niela K. Pomernacki, Natalia Udaltsova, Kristi Reynolds and Alan S. Go. Journal of the American Heart Association. 19 Jun 2013;2:e000250

8. Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation: Fox KAA, Lucas JE, Pieper KS, et al. BMJ Open 2017;7:e017157. doi:10.1136/bmjopen-2017-017157

9. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study: Friberg L, Rosenqvist M, Lip GY. Eur Heart J. 2012 Jun;33(12):1500-10. doi: 10.1093/eurheartj/ehr488. Epub 2012 Jan 13. PMID: 22246443.

10. Comparative Validation of a Novel Risk Score for Predicting Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: The HAS-BLED Score: Lip GY, Frison L, Halperin J, Lane D.
    J Am Coll Cardiol. 2011 Jan, 57 (1) 173-180.

Calculations

• The absolute risk reduction (ARR) and relative risk reduction (RRR) are calculated using stroke rates with no therapy and placebo, and stroke +SEE for the DOACs. The risk of stroke with no therapy is based upon the CHA₂DS₂-VASc absolute event rates as reported by BMJ 2011;342:d124.
• The aspirin and warfarin RRRs are from Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD001927. DOI: 10.1002/14651858.CD001927.pub2, Ann Intern Med. 2007;146:857–867 , and Cochrane Database Syst Rev 2005; CD001925.
• The apixaban RRR is imputed from placebo using the above (warfarin RRR 66% / RR 0.33) plus the ARISTOTLE HR of 0.79. Imputed apixaban effect vs. Placebo/no therapy is RR 0.26 / RRR 74%. The ARR varies by the patient’s individual stroke risk.
• GARFIELD-AF stroke and mortality risk formulas were sourced from the GARFIELD-AF registry of the Thrombosis Research Institute (with permission). These source formulas can be found here.
• As part of the 2023 Atrial Fibrillation Guideline update for this app, CHA₂DS₂-VASc risk magnitudes for “No Therapy” were updated to reflect ischemic stroke risk magnitudes from the Friberg 2012 study.
• ATRIA risk model’s stroke risk magnitude calculation was based on Table 8: Three Validated Risk Models for Stroke from the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. This table is able to be found in the Resources section of this app.

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When was this App last updated?

July 2024

How can I provide feedback?

Click here to fill out our feedback survey

How is this App intended to be used?

Use the updated AnticoagEvaluator to make informed decisions on initiation of antithrombotic therapy for patients with atrial fibrillation, in the absence of moderate to severe mitral stenosis or a mechanical heart valve. App updates include expanded advice from the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.

• Calculate a patient's stroke risk (CHA₂DS₂-VASc, ATRIA, and GARFIELD-AF) and renal function (Cockcroft-Gault Equation), and review factors that may contribute to bleed risk (HAS-BLED criteria and concomitant meds).
• Calculate a patient’s mortality risk (GARFIELD-AF).
• Consider updated stroke prevention therapy guidance based on the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation.
• Improve accurate use of DOACs with adjusted dosage based on prescribing information, fine-tuned for renal and other patient characteristics.
• Evaluate appropriate therapy for a patient by reviewing:
  • Synthesized individualized risk for antithrombotic therapy options based on clinical trials (e.g., ACTIVE-A, RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE-AF)
  • Relevant safety information and full prescribing information for all therapy options

The information and recommendations in this app are intended to support clinical decision making. They are not intended to represent the only or best course of care, or to replace clinical judgment for diagnosis, cure, mitigation, treatment, or prevention of disease. Use of this app assumes clinicians will conduct a full evaluation of the patient, consult relevant medical specialists as needed, and utilize a team-based approach to optimize therapy. In addition, therapeutic options should be determined after discussion between the patient and their care provider.

How was this App developed?

The app was developed as part of the ongoing mission of the College to generate and deliver actionable knowledge at the point of care to improve quality, efficiency, and patient outcomes. This app was originally developed as part of the ACC’s Anticoagulation Initiative, a comprehensive quality effort to improve care for patients on anticoagulation therapy. Financial support for the development of the app was provided by Daiichi Sankyo, Inc. All content was independently developed with no sponsor involvement.

The GARFIELD-AF and ATRIA risk models were incorporated into this app by expanding the Patient Information parameters and applicable Risk Factors beyond CHA₂DS₂-VASc to satisfy all three models. The risk bar above will display the risk model with the highest resulting stroke risk magnitude once risk factors are selected. All risk models’ annual stroke risk magnitudes are available on the Review Therapy tab in the Evaluate Therapy section for further review, however. A detailed table of which risk factors affect which risk model is available in the Resources section of this app.

The adjusted annual risk of stroke calculations for therapy selection in the CHA₂DS₂-VASc risk model were adapted from a web tool created by Peter Loewen, B.Sc.(Pharm), ACPR, Pharm.D., FCSHP, which can be viewed at http://www.sparctool.com/. The App was further refined and vetted through review and user testing by physicians, nurse practitioners, pharmacists, and other relevant specialists. It combines risk estimates from clinical prediction rules (i.e., CHA₂DS₂-VASc) with relative risk data from clinical trials (e.g., ACTIVE-A, RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE-AF) to produce individualized efficacy estimates for patients. A detailed description of this methodology can be found at http://www.sparctool.com/sparcnotes.htm. Because relative risk effect sizes in this therapeutic area are quite stable across the spectrum of absolute risk, this method allows for reasonable comparison between clinical research studies that used different methodologies and study populations. Nonetheless, this type of approach is no substitute for sound clinical judgment.

Please see the Resources section of this App for links to additional references.

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