The updated NICE guideline on atrial fibrillation diagnosis and management recommends offering a direct-acting oral anticoagulant to people with atrial fibrillation and a high risk of stroke (CHA2DS2-VASc score ≥2), taking into account the risk of bleeding.
For men with a moderate risk of stroke (CHA2DS2-VASc score 1), a direct-acting oral anticoagulant should be considered.
Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used as specified in the relevant NICE technology appraisals.
The technology appraisals for apixaban, edoxaban and rivaroxaban recommend the drugs as options for preventing stroke and systemic embolism in adults with non-valvular atrial fibrillation and at least one risk factor, such as previous stroke or TIA, age ≥75 years, hypertension, diabetes or symptomatic heart failure. Dabigatran is an option when patients have at least one of the following risk factors:
- previous stroke, TIA or systemic embolism
- LVEF <40%
- symptomatic heart failure (NYHA class II or above)
- age ≥75 years
- age ≥65 years with diabetes, coronary artery disease or hypertension.
A vitamin K antagonist such as warfarin is recommended as an alternative if direct-acting oral anticoagulants are contraindicated, not tolerated or otherwise unsuitable.
The updated guideline also addresses other areas where new evidence has become available since publication of the previous guideline in 2014, including the use of tools to calculate the risk of bleeding.
Evidence shows that a tool called ORBIT is the most accurate one for predicting the risk of bleeding in people with atrial fibrillation. However, the guideline acknowledges that other bleeding risk tools, including HAS-BLED which NICE’s previous guideline recommended, may need to be used until ORBIT is embedded in clinical pathways and electronic systems used by clinicians.