Antithrombotic Therapy for Atrial Fibrillation, Valvular Heart Disease, Management of Elevated INRs, and Perioperative Management

Abstract

This chapter will concisely summarize the following sections of the anticoagulation guidelines (for management of deep vein thrombosis [DVT]/pulmonary embolism [PE], see chapter on DVT/PE):

• 1. Prevention of venous thromboembolism (VTE).

• 2. Antithrombotic therapy in atrial fibrillation (AF).

• 3. Antithrombotic therapy in valvular heart disease—native and prosthetic.

• 4. Management of elevated international normalized ratios (INRs) or bleeding in patients receiving vitamin K antagonists (VKA).

• 5. Managing anticoagulation therapy in patients requiring invasive procedures (1).

The recommendations from the American College of Chest Physicians (ACCP) employ a grading system originally described in 2001. If experts are very certain that benefits do, or do not, outweigh risks, burdens, and costs, they will make a strong recommendation (grade 1). If they are less certain of the magnitude of the benefits and the risks, burdens, and costs, and thus of their relative impact, they make a weaker grade 2 recommendation. Consistent results from randomized clinical trial (RCTs) generate grade A recommendations. Observational studies with very strong effects or secure generalizations from RCTs generate grade C+. Inconsistent results from RCTs generate grade B recommendations and observational studies generate grade C recommendations.