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The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 58-year-old woman is evaluated during a routine physical examination. She has a history of atrial fibrillation and had an atrial fibrillation ablation procedure 6 months ago. Before her ablation, she had persistent atrial fibrillation with palpitations and dyspnea. Since her ablation, she has been asymptomatic with no palpitations. Ambulatory electrocardiographic monitoring at 3 and 6 months after the ablation demonstrated no atrial fibrillation. Medical history is also significant for a transient ischemic attack, hypertension, and hyperlipidemia. Her medications are warfarin, metoprolol, candesartan, and simvastatin.

On physical examination, the patient is afebrile, blood pressure is 130/80 mm Hg, pulse rate is 64/min, and respiration rate is 16/min. BMI is 30. Heart rate and rhythm are regular.

An electrocardiogram shows normal sinus rhythm.

Q.

Which of the following is the most appropriate management?

This patient should continue taking warfarin. She has a history of symptomatic atrial fibrillation and is now symptom-free without evidence of recurrent atrial fibrillation after catheter ablation. However, patients with successful ablation and elimination of symptoms may have transient asymptomatic atrial fibrillation with continued risk for atrial fibrillation-associated thromboembolic disease. Therefore, current consensus recommendations counsel that stroke prevention therapy following atrial fibrillation ablation be based on risk factors and not rhythm status, with the preferred risk stratification tool being the CHA2DS2-VASc risk score, which has improved predictive ability relative to the CHADS2 score. The patient is a 58-year-old woman with a prior transient ischemic attack (TIA) and hypertension. Accordingly, her CHA2DS2-VASc risk score is 4 (2 points for TIA, 1 point for hypertension, and 1 point for female sex). Current guidelines advocate oral anticoagulation for any patient with nonvalvular atrial fibrillation and a CHA2DS2-VASc score greater than 1. She has a history of a central nervous system event, and her annual risk of stroke is high (greater than 5% annually). Therefore, she should be continued on anticoagulation with warfarin.

Concomitant aspirin therapy with warfarin is reserved for patients with active coronary artery disease. This patient has risk factors for atherosclerosis, but she does not have a history of coronary artery disease or acute coronary syndromes. The addition of aspirin to warfarin significantly increases the risk of bleeding.

Discontinuation of warfarin and substitution with aspirin or dual antiplatelet therapy is not correct. Aspirin is insufficient therapy for a patient at high risk of stroke. The Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE-W) trial compared warfarin with therapy with aspirin and clopidogrel and found that aspirin with clopidogrel was inferior to warfarin for stroke prevention with no statistically significant difference in bleeding.

Anticoagulation with a novel oral anticoagulant (such as dabigatran, rivaroxaban, or apixaban) could be considered; however, these agents have been associated with increased gastrointestinal bleeding compared with warfarin.

Key Point

  • Stroke prevention therapy after catheter ablation of atrial fibrillation should be based upon risk stratification, not heart rhythm status.
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