A Clinical Decision Aid for the Selection of Antithrombotic Therapy for the Prevention of Stroke Due to Atrial Fibrillation

Study Questions:

Can a clinical decision aid assist in identifying the most appropriate antithrombotic therapy for patients with nonvalvular atrial fibrillation (AF)?


The annual risks of stroke and major bleeding were estimated for the following treatment options: no therapy; aspirin; aspirin plus clopidogrel, 75 mg/day; warfarin; dabigatran, 110 or 150 mg twice daily; apixaban, 5 mg twice daily; and rivaroxaban, 20 mg/day. These risks were based on data from randomized clinical trials and the Danish National Patient Registry. The risk of stroke/systemic emboli (SSE) was stratified by the CHA2DS2-VASc score, and the risk of major bleeding was stratified by the HAS-BLED score. Treatment threshold was defined as the minimum absolute risk reduction of SSE for a patient to agree to antithrombotic therapy, and the cost threshold was defined as the maximum a patient is willing to pay per day to reduce the risk of SSE.


Treatment recommendations were developed according to user-specified criteria. The user-specified criteria are the CHA2DS2-VASc and HAS-BLED scores and the treatment and cost thresholds. For example, for a cost threshold of $0.50, a treatment threshold of 0.5%, CHA2DS2-VASc = 1, and HAS-BLED = 0, warfarin is the recommended treatment. With a similar scenario, but a cost threshold of $4.00, apixaban or dabigatran, 150 mg twice daily, are recommended over warfarin.


The authors concluded that recommendations based on user-specified criteria can assist clinicians in selecting the optimal antithrombotic therapy for patients with AF.


Many clinicians follow recommendations for stroke-prevention therapy that are based solely on the CHADS2 or CHA2DS2-VASc score. The clinical decision aid developed in this study allows for recommendations that are much more patient-specific.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Novel Agents

Keywords: Stroke, Benzimidazoles, Warfarin, Atrial Fibrillation, Pyrazoles

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