Thomson et al developed guidelines for anticoagulant therapy to prevent stroke in patients with atrial fibrillation. A Markov model was used for the decision making about the warfarin therapy. The study was done at Newcastle Upon Tyne in the United Kingdom.
Risk factors used in study (reported as "Yes" or "No"):
(1) current smoking
(2) taking antihypertensive medication
(3) diabetes mellitus
(4) cardiovascular disease
(5) left ventricular hypertrophy
Flowchart for patient with atrial fibrillation or flutter:
(1) Consider rate control and need for cardiology consultation (for atrial conversion if acute onset, etc.)
(2) Does the patient have a characteristic which may make anticoagulation hazardous, or is warfarin contraindicated?
(2a) If Yes: Seek further advice from colleagues or treat with aspirin.
(2b) If No: Go to (3)
(3) Does the patient have (a) 3 or more risk factors, OR (b) male with left ventricular hypertrophy and 1 other risk factor, OR (c) a history of minor stroke or transient ischemic attack (TIA)?
(3a) If Yes: Treat with warfarin.
(3b) If No: Go to (4)
(4) Look up recommendation in following tables based on patient gender, risk factors and blood pressure.
(4a) Yes = clear benefit from treatment
(4b) BL = borderline = benefit only at upper end of age range
(4c) No = no benefit from treatment
where:
• If step 4 is reached and age is < 60, systolic blood pressure is < 110 or systolic blood pressure is > 180, then in the implementation the patient is referred to a cardiologist.
• characteristics making anticoagulation hazardous
• contraindications for warfarin
• Aspirin may be contraindicated in some patients (allergy, etc.). In the implementation I've used anti-platelet agent as the recommendation.
Additional treatment notes:
(1) Some risk factors (smoking, status of blood pressure) are modifiable and this should be taken into account before reaching a final treatment plan.
(2) Patients should be reassessed at least annually.
(3) Patient preferences or personal parameters may affect choice of therapy.
Table for Men 60 to 85+
|
Age |
Risk Factors |
Blood Pressure in mm Hg |
||||||
|
|
|
110 |
120 |
130 |
140 |
150 |
160 |
170 |
|
60-64 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
DM or HT |
No |
No |
No |
No |
No |
BL |
Yes |
|
|
Cig or CVD |
No |
No |
No |
No |
Yes |
Yes |
Yes |
|
|
DM+HT |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
LVH |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
Cigs+CVD |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
65-69 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
DM or HT |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
Cig or CVD |
No |
No |
No |
No |
Yes |
Yes |
Yes |
|
|
DM+HT |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
LVH |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
Cigs+CVD |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
70-74 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
DM or HT |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
Cig or CVD |
No |
No |
No |
No |
Yes |
Yes |
Yes |
|
|
DM+HT |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
LVH |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
Cigs+CVD |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
75-79 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
DM or HT |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
Cig or CVD |
No |
No |
No |
No |
Yes |
Yes |
Yes |
|
|
DM+HT |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
LVH |
No |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo |
No |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
Cigs+CVD |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
80-84 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
DM or HT |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
Cig or CVD |
No |
No |
No |
BL |
Yes |
Yes |
Yes |
|
|
DM+HT |
No |
No |
BL |
Yes |
Yes |
Yes |
Yes |
|
|
LVH |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
Cigs+CVD |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
85+ |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
DM or HT |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
Cig or CVD |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
DM+HT |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
LVH |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
Cigs+CVD |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
from Figure 2 page 959
where:
• BL = borderline, with benefit only at upper end of age range
• HT = hypertension
• DM = diabetes mellitus
• Cigs = current smoker
• CVD = presence of cardiovascular disease
• LVH = presence of left ventricular hypertrophy
• combo = (DM or HT) + (Cigs or CVD)
Table for Women 60 to 85+
|
Age |
Risk Factors |
Blood Pressure in mm Hg |
||||||
|
|
|
110 |
120 |
130 |
140 |
150 |
160 |
170 |
|
60-64 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
CVD |
No |
No |
No |
No |
No |
No |
BL |
|
|
DM or Cigs |
No |
No |
No |
No |
No |
No |
Yes |
|
|
HT |
No |
No |
No |
No |
No |
No |
No |
|
|
LVH |
No |
No |
No |
No |
BL |
Yes |
Yes |
|
|
combo 1 |
No |
No |
No |
BL |
Yes |
Yes |
Yes |
|
|
DM+Cigs |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+LVH |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 2 |
No |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+HT |
No |
BL |
BL |
Yes |
Yes |
Yes |
Yes |
|
|
combo 3 |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
LVH+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
65-69 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
CVD |
No |
No |
No |
No |
No |
No |
Yes |
|
|
DM or Cigs |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
HT |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
LVH |
No |
No |
No |
No |
Yes |
Yes |
Yes |
|
|
combo 1 |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
DM+Cigs |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+LVH |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 2 |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 3 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
LVH+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
70-74 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
CVD |
No |
No |
No |
No |
No |
BL |
Yes |
|
|
DM or Cigs |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
HT |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
LVH |
No |
No |
No |
No |
Yes |
Yes |
Yes |
|
|
combo 1 |
No |
No |
No |
BL |
Yes |
Yes |
Yes |
|
|
DM+Cigs |
No |
No |
BL |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+LVH |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 2 |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 3 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
LVH+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
75-79 |
none |
No |
No |
No |
No |
No |
No |
No |
|
|
CVD |
No |
No |
No |
No |
No |
Yes |
Yes |
|
|
DM or Cigs |
No |
No |
No |
No |
BL |
Yes |
Yes |
|
|
HT |
No |
No |
No |
BL |
BL |
Yes |
Yes |
|
|
LVH |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
combo 1 |
No |
No |
BL |
Yes |
Yes |
Yes |
Yes |
|
|
DM+Cigs |
No |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+LVH |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 2 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 3 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
LVH+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
80-84 |
none |
No |
No |
No |
No |
No |
No |
BL |
|
|
CVD |
No |
No |
No |
No |
BL |
Yes |
Yes |
|
|
DM or Cigs |
No |
No |
No |
BL |
Yes |
Yes |
Yes |
|
|
HT |
No |
No |
BL |
Yes |
Yes |
Yes |
Yes |
|
|
LVH |
No |
No |
BL |
Yes |
Yes |
Yes |
Yes |
|
|
combo 1 |
No |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
DM+Cigs |
BL |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+LVH |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 2 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 3 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
LVH+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
85+ |
none |
No |
No |
No |
No |
No |
No |
Yes |
|
|
CVD |
No |
No |
No |
No |
Yes |
Yes |
Yes |
|
|
DM or Cigs |
No |
No |
No |
Yes |
Yes |
Yes |
Yes |
|
|
HT |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
LVH |
No |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 1 |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
DM+Cigs |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+LVH |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 2 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
CVD+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
combo 3 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
|
LVH+HT |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
from Figure 3 page 960
where:
• BL = borderline, with benefit only at upper end of age range
• HT = hypertension
• DM = diabetes mellitus
• Cigs = current smoker
• CVD = presence of cardiovascular disease
• LVH = presence of left ventricular hypertrophy
• combo 1 = (DM or Cigs) + CVD
• combo 2 = (DM or Cigs) + LVH
• combo 3 = (DM or Cigs) + HT
Specialty: Hematology Oncology, Neurology, Clinical Laboratory, Pharmacology, clinical
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