Expert Review of Cardiovascular Therapy
ISSN: 1477-9072 (Print) 1744-8344 (Online) Journal homepage: http://www.tandfonline.com/loi/ierk20
Nonsteroidal anti-inflammatory drugs and bleeding risk in anticoagulated patients with atrial fibrillation Gregory YH Lip To cite this article: Gregory YH Lip (2015) Nonsteroidal anti-inflammatory drugs and bleeding risk in anticoagulated patients with atrial fibrillation, Expert Review of Cardiovascular Therapy, 13:9, 963-965, DOI: 10.1586/14779072.2015.1071665 To link to this article: http://dx.doi.org/10.1586/14779072.2015.1071665
Published online: 21 Jul 2015.
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Article views: 341
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ierk20 Download by: [178.77.155.210]
Date: 23 February 2016, At: 14:19
Editorial
Nonsteroidal anti-inflammatory drugs and bleeding risk in anticoagulated patients with atrial fibrillation Expert Rev. Cardiovasc. Ther. 13(9), 963–965 (2015)
Expert Review of Cardiovascular Therapy 2015.13:963-965.
Gregory YH Lip University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark [email protected]
Although nonsteroidal anti-inflammatory drugs (NSAIDs) have generally conferred increased gastrointestinal bleeding risk, the data for bleeding risks with these drugs in anticoagulated atrial fibrillation (AF) patients per se were much more limited. Recent evidence shows that concomitant use of NSAIDs in anticoagulated AF patients carries a real risk of serious bleeding, as well as thromboembolism. Thus, physicians should clearly exercise extra caution with NSAIDs in patients with AF, especially if they are anticoagulated. Also, AF patients with NSAIDs should also undergo regular clinical review, and clinicians should regularly reassess the need for NSAID use. Finally, as a part of regular clinical assessment, bleeding risk should be routinely assessed, and the HAS-BLED score is now recommended in many guidelines for this purpose.
In clinical practice, bleeding risk in patients with atrial fibrillation (AF) can be associated with a number of clinical features [1]. It has been well-recognized that adding aspirin to oral anticoagulation (OAC) substantially increases bleeding risks, especially that of intracranial hemorrhage [2]. Although nonsteroidal anti-inflammatory drugs (NSAIDs) have generally conferred increased gastrointestinal bleeding risk, the data for bleeding risks with these drugs in anticoagulated AF patients per se were much more limited, although it was generally presumed that adding NSAIDs to anticoagulation would – such as aspirin – confer excess risk [2,3]. Regular NSAID use was often an exclusion criteria for randomized trials of anticoagulants for stroke prevention in AF. In a recent analysis of 150,900 patients with AF from the Danish nationwide cohort study, Lamberts et al. [4] show that the use of NSAIDs was associated with an independent risk for serious bleeding and thromboembolism in patients with AF. Also, short-term NSAID exposure was associated with increased bleeding risk. Importantly, this article also examines different NSAID types, including both
selective (e.g., rofecoxib and celecoxib) and nonselective (e.g., ibuprofen, diclofenac and naproxen). The increased absolute risks for serious bleeding and thromboembolism were seen across all antithrombotic regimens and NSAID types. Also, higher NSAID doses (e.g., above the recommended minimum) was associated with a substantially increased hazard ratio for bleeding. The article by Lamberts et al. [4] is limited by its observational design and unmeasured confounders. However, clinical trial cohorts may not answer this question because regular NSAID use is often an exclusion criterion for trials examining anticoagulants. NSAID use may also be a surrogate marker for associated comorbidities that could have contributed to the excess risks of thromboembolism and bleeding. Indeed, an increased risk of thrombosis-related complications has been noted with the selective NSAIDs [5], but this has not been previously reported for AF patients per se. The Danish registries also do not provide data on quality of anticoagulation control, and we should recognize that labile international normalised ratio (INR) (as reflected by a
KEYWORDS: aspirin . atrial fibrillation . bleeding . NSAID . warfarin
informahealthcare.com
10.1586/14779072.2015.1071665
2015 Informa UK Ltd
ISSN 1477-9072
963
Expert Review of Cardiovascular Therapy 2015.13:963-965.
Editorial
Lip
poor time in therapeutic range [TTR]) is strongly associated with an increased risk of both thromboembolism and bleeding [6]. Although TTRs in Denmark have generally been high in clinical trials, current recommendations suggest aiming for a TTR >70% to achieve best efficacy and safety outcomes from the use of warfarin [7]. Nonetheless, TTR in AF patients can be influenced by many clinical features, which can be predicted by simple clinical scores such as the SAMe-TT2R2 score [8]. Finally, the article by Lamberts et al. deals with oral anticoagulation using warfarin, but with the increasing use of non-vitamin K OACs (NOACs, previously referred to as new or novel OACs[9]), the propensity to gastrointestinal bleeding with combination therapy is even more relevant, especially since some NOACs (dabigatran 150 mg b.i.d., rivaroxaban and edoxaban 60 mg o.d.) were associated with more gastrointestinal bleeding compared with warfarin in their respective clinical trials and from indirect comparisons – with important implications for translation to clinical practice [10–12]. What are the implications for patient management? First, physicians should clearly exercise extra caution with NSAIDs in patients with AF, especially if they are anticoagulated. Indeed, the proportion getting anticoagulation is greater since even one stroke risk factor confers a substantial risk of ischemic stroke and mortality than is lowered by OAC use [13–16]. Second, AF patients with NSAIDs should also undergo regular clinical review, and clinicians should regularly reassess the need for NSAID use. Finally, as a part of regular clinical assessment, bleeding risk should be routinely assessed, and the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) score [17] is now recommended in many guidelines for this purpose. The D criterion in HAS-BLED refers to concomitant use of aspirin or NSAIDs; indeed, a high HAS-BLED score enables physicians to ‘flag up’ the patients potentially at risk of bleeding, as well as to address the use of potentially reversible bleeding risk factors (e.g., minimizing the concurrent use of NSAIDs, labile INRs, etc). References 1.
2.
Lip GY, Andreotti F, Fauchier L, et al. Bleeding risk assessment and management in atrial fibrillation patients. Executive Summary of a Position Document from the European Heart Rhythm Association [EHRA], endorsed by the European Society of Cardiology [ESC] Working Group on Thrombosis. Thromb Haemost 2011; 106(6):997-1011 Hansen ML, Sorensen R, Clausen MT, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 2010;170(16): 1433-41
964
3.
4.
5.
This is relevant since other bleeding risk scores have been proposed based on derivation or validation studies that have used highly selected cohorts (e.g., those only using a healthcare plan) or trial datasets (with high stroke risk patients or where previous severe hemorrhage or severe renal impairment have been trial exclusion criteria). Oversimplified scores that do not consider common (reversible) bleeding risk factors (e.g., concomitant NSAID use or labile INRs in a patient taking warfarin, given the close relationship of quality of anticoagulation control to efficacy and safety of warfarin [18]) would misclassify such a patient as ‘low risk’ and thus expose the patients to potential serious bleeding risks. This is in contrast to the HASBLED score that would have given additional risk points to such patients for NSAID use or labile INRs. For now, it would be important to recognize that concomitant use of NSAIDs in anticoagulated AF patients carries a real risk of serious bleeding, as well as thromboembolism. Review of anticoagulated AF patients taking regular NSAIDs – both selective and nonselective – should be made, and the necessity for such concomitant drugs needs to be fully justified. Gastric protection may help, but ultimately, that bleeding risk is multifactorial and given that our AF patient population is often elderly and has multiple comorbidities, anticoagulated AF patients should not be co-prescribed NSAIDs if one can avoid so. Even in stable vascular disease, there is really no necessity to continue prescribing aspirin in the anticoagulated AF patient given the associated excess bleeding risks and limited protective effect against thromboembolism [19,20]. Financial & competing interests disclosure
GYH Lip has served as a consultant for Bayer, Merck, Sanofi, BMS/ Pfizer, Daiichi-Sankyo, Biotronik, Medtronic, Portola and Boehringer Ingelheim and has been on the speakers bureau for Bayer, BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo and Medtronic. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Hallas J, Dall M, Andries A, et al. Use of single and combined antithrombotic therapy and risk of serious upper gastrointestinal bleeding: population based case-control study. BMJ 2006;333(7571):726 Lamberts M, Lip GY, Hansen ML, et al. Relation of nonsteroidal anti-inflammatory drugs to serious bleeding and thromboembolism risk in patients with atrial fibrillation receiving antithrombotic therapy: a nationwide cohort study. Ann Intern Med 2014;161(10):690-8 Gislason GH, Jacobsen S, Rasmussen JN, et al. Risk of death or reinfarction associated with the use of selective cyclooxygenase-2 inhibitors and nonselective nonsteroidal antiinflammatory drugs after
acute myocardial infarction. Circulation 2006;113(25):2906-13 6.
Gallego P, Roldan V, Marin F, et al. Cessation of oral anticoagulation in relation to mortality and the risk of thrombotic events in patients with atrial fibrillation. Thromb Haemost 2013;110(6):1189-98
7.
De Caterina R, Husted S, Wallentin L, et al. Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC working group on thrombosis–task force on anticoagulants in heart disease. Thromb Haemost 2013;110(6):1087-107
8.
Apostolakis S, Sullivan RM, Olshansky B, Lip GY. Factors affecting quality of
Expert Rev. Cardiovasc. Ther. 13(9), (2015)
Non-steroidal anti-inflammatory drugs
anticoagulation control among patients with atrial fibrillation on warfarin: the SAMe-TT (2)R(2) score. Chest 2013;144(5):1555-63 9.
10.
Expert Review of Cardiovascular Therapy 2015.13:963-965.
11.
12.
Husted S, de Caterina R, Andreotti F, et al. Non-vitamin K antagonist oral anticoagulants (NOACs): No longer new or novel. Thromb Haemost 2014;111(5):781-2 Skjoth F, Larsen TB, Rasmussen LH, Lip GY. Efficacy and safety of edoxaban in comparison with dabigatran, rivaroxaban and apixaban for stroke prevention in atrial fibrillation. An indirect comparison analysis. Thromb Haemost 2014;111(5):981-8 Chan NC, Paikin JS, Hirsh J, et al. New oral anticoagulants for stroke prevention in atrial fibrillation: impact of study design, double counting and unexpected findings on interpretation of study results and conclusions. Thromb Haemost 2014;111(5): 798-807 Hylek EM, Ko D, Cove CL. Gaps in translation from trials to practice: Non-vitamin K antagonist oral
informahealthcare.com
anticoagulants (NOACs) for stroke prevention in atrial fibrillation. Thromb Haemost 2014;111(5):783-8 13.
14.
15.
16.
Lip GY, Skjoth F, Rasmussen LH, Larsen TB. Oral anticoagulation, aspirin, or no therapy in patients with nonvalvular AF with 0 or 1 stroke risk factor based on the CHA2DS2-VASc score. J Am Coll Cardiol 2015;65(14):1385-94 Olesen JB, Torp-Pedersen C. Stroke risk in atrial fibrillation: Do we anticoagulate CHADS2 or CHA2DS2-VASc >/=1, or higher? Thromb Haemost 2015;113:2 Nielsen PB, Chao TF. The risks of risk scores for stroke risk assessment in atrial fibrillation. Thromb Haemost 2015;113(6): 1170-3 Chao TF, Liu CJ, Wang KL, et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (Beyond Sex) receive oral anticoagulation? J Am Coll Cardiol 2015;65(7):635-42
Editorial
17.
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):1093-100
18.
Sjogren V, Grzymala-Lubanski B, Renlund H, et al. Safety and efficacy of well managed warfarin. A report from the Swedish quality register Auricula. Thromb Haemost 2015;113(6):1370-7
19.
Bernard A, Fauchier L, Pellegrin C, et al. Anticoagulation in patients with atrial fibrillation undergoing coronary stent implantation. Thromb Haemost 2013; 110(3):560-8
20.
Rubboli A, Faxon DP, Airaksinen KE, et al. The optimal management of patients on oral anticoagulation undergoing coronary artery stenting. The 10th Anniversary Overview. Thromb Haemost 2014;112(6): 1080-7
965
ISSN: 1477-9072 (Print) 1744-8344 (Online) Journal homepage: http://www.tandfonline.com/loi/ierk20
Nonsteroidal anti-inflammatory drugs and bleeding risk in anticoagulated patients with atrial fibrillation Gregory YH Lip To cite this article: Gregory YH Lip (2015) Nonsteroidal anti-inflammatory drugs and bleeding risk in anticoagulated patients with atrial fibrillation, Expert Review of Cardiovascular Therapy, 13:9, 963-965, DOI: 10.1586/14779072.2015.1071665 To link to this article: http://dx.doi.org/10.1586/14779072.2015.1071665
Published online: 21 Jul 2015.
Submit your article to this journal
Article views: 341
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ierk20 Download by: [178.77.155.210]
Date: 23 February 2016, At: 14:19
Editorial
Nonsteroidal anti-inflammatory drugs and bleeding risk in anticoagulated patients with atrial fibrillation Expert Rev. Cardiovasc. Ther. 13(9), 963–965 (2015)
Expert Review of Cardiovascular Therapy 2015.13:963-965.
Gregory YH Lip University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark [email protected]
Although nonsteroidal anti-inflammatory drugs (NSAIDs) have generally conferred increased gastrointestinal bleeding risk, the data for bleeding risks with these drugs in anticoagulated atrial fibrillation (AF) patients per se were much more limited. Recent evidence shows that concomitant use of NSAIDs in anticoagulated AF patients carries a real risk of serious bleeding, as well as thromboembolism. Thus, physicians should clearly exercise extra caution with NSAIDs in patients with AF, especially if they are anticoagulated. Also, AF patients with NSAIDs should also undergo regular clinical review, and clinicians should regularly reassess the need for NSAID use. Finally, as a part of regular clinical assessment, bleeding risk should be routinely assessed, and the HAS-BLED score is now recommended in many guidelines for this purpose.
In clinical practice, bleeding risk in patients with atrial fibrillation (AF) can be associated with a number of clinical features [1]. It has been well-recognized that adding aspirin to oral anticoagulation (OAC) substantially increases bleeding risks, especially that of intracranial hemorrhage [2]. Although nonsteroidal anti-inflammatory drugs (NSAIDs) have generally conferred increased gastrointestinal bleeding risk, the data for bleeding risks with these drugs in anticoagulated AF patients per se were much more limited, although it was generally presumed that adding NSAIDs to anticoagulation would – such as aspirin – confer excess risk [2,3]. Regular NSAID use was often an exclusion criteria for randomized trials of anticoagulants for stroke prevention in AF. In a recent analysis of 150,900 patients with AF from the Danish nationwide cohort study, Lamberts et al. [4] show that the use of NSAIDs was associated with an independent risk for serious bleeding and thromboembolism in patients with AF. Also, short-term NSAID exposure was associated with increased bleeding risk. Importantly, this article also examines different NSAID types, including both
selective (e.g., rofecoxib and celecoxib) and nonselective (e.g., ibuprofen, diclofenac and naproxen). The increased absolute risks for serious bleeding and thromboembolism were seen across all antithrombotic regimens and NSAID types. Also, higher NSAID doses (e.g., above the recommended minimum) was associated with a substantially increased hazard ratio for bleeding. The article by Lamberts et al. [4] is limited by its observational design and unmeasured confounders. However, clinical trial cohorts may not answer this question because regular NSAID use is often an exclusion criterion for trials examining anticoagulants. NSAID use may also be a surrogate marker for associated comorbidities that could have contributed to the excess risks of thromboembolism and bleeding. Indeed, an increased risk of thrombosis-related complications has been noted with the selective NSAIDs [5], but this has not been previously reported for AF patients per se. The Danish registries also do not provide data on quality of anticoagulation control, and we should recognize that labile international normalised ratio (INR) (as reflected by a
KEYWORDS: aspirin . atrial fibrillation . bleeding . NSAID . warfarin
informahealthcare.com
10.1586/14779072.2015.1071665
2015 Informa UK Ltd
ISSN 1477-9072
963
Expert Review of Cardiovascular Therapy 2015.13:963-965.
Editorial
Lip
poor time in therapeutic range [TTR]) is strongly associated with an increased risk of both thromboembolism and bleeding [6]. Although TTRs in Denmark have generally been high in clinical trials, current recommendations suggest aiming for a TTR >70% to achieve best efficacy and safety outcomes from the use of warfarin [7]. Nonetheless, TTR in AF patients can be influenced by many clinical features, which can be predicted by simple clinical scores such as the SAMe-TT2R2 score [8]. Finally, the article by Lamberts et al. deals with oral anticoagulation using warfarin, but with the increasing use of non-vitamin K OACs (NOACs, previously referred to as new or novel OACs[9]), the propensity to gastrointestinal bleeding with combination therapy is even more relevant, especially since some NOACs (dabigatran 150 mg b.i.d., rivaroxaban and edoxaban 60 mg o.d.) were associated with more gastrointestinal bleeding compared with warfarin in their respective clinical trials and from indirect comparisons – with important implications for translation to clinical practice [10–12]. What are the implications for patient management? First, physicians should clearly exercise extra caution with NSAIDs in patients with AF, especially if they are anticoagulated. Indeed, the proportion getting anticoagulation is greater since even one stroke risk factor confers a substantial risk of ischemic stroke and mortality than is lowered by OAC use [13–16]. Second, AF patients with NSAIDs should also undergo regular clinical review, and clinicians should regularly reassess the need for NSAID use. Finally, as a part of regular clinical assessment, bleeding risk should be routinely assessed, and the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) score [17] is now recommended in many guidelines for this purpose. The D criterion in HAS-BLED refers to concomitant use of aspirin or NSAIDs; indeed, a high HAS-BLED score enables physicians to ‘flag up’ the patients potentially at risk of bleeding, as well as to address the use of potentially reversible bleeding risk factors (e.g., minimizing the concurrent use of NSAIDs, labile INRs, etc). References 1.
2.
Lip GY, Andreotti F, Fauchier L, et al. Bleeding risk assessment and management in atrial fibrillation patients. Executive Summary of a Position Document from the European Heart Rhythm Association [EHRA], endorsed by the European Society of Cardiology [ESC] Working Group on Thrombosis. Thromb Haemost 2011; 106(6):997-1011 Hansen ML, Sorensen R, Clausen MT, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 2010;170(16): 1433-41
964
3.
4.
5.
This is relevant since other bleeding risk scores have been proposed based on derivation or validation studies that have used highly selected cohorts (e.g., those only using a healthcare plan) or trial datasets (with high stroke risk patients or where previous severe hemorrhage or severe renal impairment have been trial exclusion criteria). Oversimplified scores that do not consider common (reversible) bleeding risk factors (e.g., concomitant NSAID use or labile INRs in a patient taking warfarin, given the close relationship of quality of anticoagulation control to efficacy and safety of warfarin [18]) would misclassify such a patient as ‘low risk’ and thus expose the patients to potential serious bleeding risks. This is in contrast to the HASBLED score that would have given additional risk points to such patients for NSAID use or labile INRs. For now, it would be important to recognize that concomitant use of NSAIDs in anticoagulated AF patients carries a real risk of serious bleeding, as well as thromboembolism. Review of anticoagulated AF patients taking regular NSAIDs – both selective and nonselective – should be made, and the necessity for such concomitant drugs needs to be fully justified. Gastric protection may help, but ultimately, that bleeding risk is multifactorial and given that our AF patient population is often elderly and has multiple comorbidities, anticoagulated AF patients should not be co-prescribed NSAIDs if one can avoid so. Even in stable vascular disease, there is really no necessity to continue prescribing aspirin in the anticoagulated AF patient given the associated excess bleeding risks and limited protective effect against thromboembolism [19,20]. Financial & competing interests disclosure
GYH Lip has served as a consultant for Bayer, Merck, Sanofi, BMS/ Pfizer, Daiichi-Sankyo, Biotronik, Medtronic, Portola and Boehringer Ingelheim and has been on the speakers bureau for Bayer, BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo and Medtronic. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Hallas J, Dall M, Andries A, et al. Use of single and combined antithrombotic therapy and risk of serious upper gastrointestinal bleeding: population based case-control study. BMJ 2006;333(7571):726 Lamberts M, Lip GY, Hansen ML, et al. Relation of nonsteroidal anti-inflammatory drugs to serious bleeding and thromboembolism risk in patients with atrial fibrillation receiving antithrombotic therapy: a nationwide cohort study. Ann Intern Med 2014;161(10):690-8 Gislason GH, Jacobsen S, Rasmussen JN, et al. Risk of death or reinfarction associated with the use of selective cyclooxygenase-2 inhibitors and nonselective nonsteroidal antiinflammatory drugs after
acute myocardial infarction. Circulation 2006;113(25):2906-13 6.
Gallego P, Roldan V, Marin F, et al. Cessation of oral anticoagulation in relation to mortality and the risk of thrombotic events in patients with atrial fibrillation. Thromb Haemost 2013;110(6):1189-98
7.
De Caterina R, Husted S, Wallentin L, et al. Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC working group on thrombosis–task force on anticoagulants in heart disease. Thromb Haemost 2013;110(6):1087-107
8.
Apostolakis S, Sullivan RM, Olshansky B, Lip GY. Factors affecting quality of
Expert Rev. Cardiovasc. Ther. 13(9), (2015)
Non-steroidal anti-inflammatory drugs
anticoagulation control among patients with atrial fibrillation on warfarin: the SAMe-TT (2)R(2) score. Chest 2013;144(5):1555-63 9.
10.
Expert Review of Cardiovascular Therapy 2015.13:963-965.
11.
12.
Husted S, de Caterina R, Andreotti F, et al. Non-vitamin K antagonist oral anticoagulants (NOACs): No longer new or novel. Thromb Haemost 2014;111(5):781-2 Skjoth F, Larsen TB, Rasmussen LH, Lip GY. Efficacy and safety of edoxaban in comparison with dabigatran, rivaroxaban and apixaban for stroke prevention in atrial fibrillation. An indirect comparison analysis. Thromb Haemost 2014;111(5):981-8 Chan NC, Paikin JS, Hirsh J, et al. New oral anticoagulants for stroke prevention in atrial fibrillation: impact of study design, double counting and unexpected findings on interpretation of study results and conclusions. Thromb Haemost 2014;111(5): 798-807 Hylek EM, Ko D, Cove CL. Gaps in translation from trials to practice: Non-vitamin K antagonist oral
informahealthcare.com
anticoagulants (NOACs) for stroke prevention in atrial fibrillation. Thromb Haemost 2014;111(5):783-8 13.
14.
15.
16.
Lip GY, Skjoth F, Rasmussen LH, Larsen TB. Oral anticoagulation, aspirin, or no therapy in patients with nonvalvular AF with 0 or 1 stroke risk factor based on the CHA2DS2-VASc score. J Am Coll Cardiol 2015;65(14):1385-94 Olesen JB, Torp-Pedersen C. Stroke risk in atrial fibrillation: Do we anticoagulate CHADS2 or CHA2DS2-VASc >/=1, or higher? Thromb Haemost 2015;113:2 Nielsen PB, Chao TF. The risks of risk scores for stroke risk assessment in atrial fibrillation. Thromb Haemost 2015;113(6): 1170-3 Chao TF, Liu CJ, Wang KL, et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (Beyond Sex) receive oral anticoagulation? J Am Coll Cardiol 2015;65(7):635-42
Editorial
17.
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):1093-100
18.
Sjogren V, Grzymala-Lubanski B, Renlund H, et al. Safety and efficacy of well managed warfarin. A report from the Swedish quality register Auricula. Thromb Haemost 2015;113(6):1370-7
19.
Bernard A, Fauchier L, Pellegrin C, et al. Anticoagulation in patients with atrial fibrillation undergoing coronary stent implantation. Thromb Haemost 2013; 110(3):560-8
20.
Rubboli A, Faxon DP, Airaksinen KE, et al. The optimal management of patients on oral anticoagulation undergoing coronary artery stenting. The 10th Anniversary Overview. Thromb Haemost 2014;112(6): 1080-7
965
