E. Start warfarin – Explanation
This patient has atrial fibrillation. As a consequence he has had a number of transient ischaemic
attacks (TIAs) and hence needs to be anticoagulated with warfarin.
In patients who’ve had an ischaemic stroke the guidelines recommend waiting two weeks before
anticoagulation is commenced to reduce the risk of haemorrhagic transformation. However, NICE
recommend for TIA patients: ‘in the absence of cerebral infarction or haemorrhage, anticoagulation
therapy should begin as soon as possible.’
Atrial fibrillation: anticoagulation
The European Society of Cardiology published updated guidelines on the management of atrial
fibrillation in 2012. They suggest using the CHA2DS2-VASc score to determine the most appropriate
anticoagulation strategy.
This scoring system superceded the CHADS2score.
| Condition | Points | |
| C | Congestive heart failure | 1 |
| H | Hypertension (or treated hypertension) | 1 |
| A2 | Age >= 75 years | 2 |
| D | Diabetes | 1 |
| S2 | Prior Stroke or TIA | 2 |
| V | Vascular disease (including ischaemic heart disease and peripheral arterial disease) | 1 |
| A | Age 65-74 years | 1 |
| S | Sex (female) | 1 |
The table below shows a suggested anticoagulation strategy* based on the score:
Score………… Anticoagulation
…0 ……………No treatment is preferred to aspirin
…1 ……………Oral anticoagulants preferred to aspirin; dabigatran is an alternative
…2 or more….. Oral anticoagulants; dabigatran is an alternative*the wording in the guidelines (‘is preferred to’) can
be slightly confusing. It basically means that, say for a score of 0, whilst aspirin is an acceptable
management option the weight of the clinical evidence would support no treatment instead
