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Stroke Prevention in Atrial Fibrillation Risk Tool
for estimating risk of stroke and benefits & risks of antithrombotic therapy in patients with chronic nonvalvular atrial fibrillation
developed by Peter Loewen, ACPR, Pharm.D., FCSHP
MAJOR UPDATE
				notes/references
DISCLAIMER: this tool may be used unaltered for learning purposes and the author assumes no responsibility whatsoever for any decisions or harms to anyone resulting from its use. The author makes no representations, conditions or warranties, either expressed or implied, regarding this tool.
In your patient with atrial fibrillation, which of the following stroke or bleeding risk factors are present?
Stroke Risk (CHA2DS2-VASc)
age<65 age 65-74 age 75+
	CHF/LV dysfunction
	Hypertension (controlled or uncontrolled)
	Diabetes Type I or II (controlled or uncontrolled)
	TIA or stroke (at any time in the past)
	Prior MI, peripheral artery disease, or aortic plaque
	Female
CHA2DS2-VASc SCORE (0-9):
Major Bleeding Risk (HAS-BLED)
	Abnormal renal function (dialysis, SCr>200 mcmol/L, or transplant)
	Hypertension (SBP>160 mmHg)
	Abnormal liver function (cirrhosis or liver enzymes>3x ULN)
	History of major bleeding (any cause)
	History of labile INR (time in therapeutic range <60%)
	Current use of alcohol>8 drinks/week
	Currently taking antiplatelet drug or NSAID
HAS-BLED SCORE (0-9):
therapy option	annual risk of stroke/embolism		annual risk of major bleeding (intracranial bleeding, bleeding requiring hospitalization, HgB decrease of > 20 g/L, or need for transfusion)		net clinical benefit (strokes prevented per major bleed caused)
no therapy					n/a
ASA
ASA + clopidogrel
warfarin
dabigatran 110
dabigatran 150
rivaroxaban
apixaban
edoxaban 30
edoxaban 60
no therapy
Patient's ANNUAL risk of ischemic stroke+thromboembolism with no therapy:
Patient's annual risk of stroke or TIA with no therapy if they DID NOT HAVE AF (for comparison):
ANNUAL risk of major bleed with no therapy:
ASA 80-325mg/d
not recommended by most international AF guidelines due to inferior efficacy vs. OACs with similar risk of major bleeding
Patient's annual risk of ischemic stroke+thromboembolism with ASA:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):
ASA 75-100mg/d + clopidogrel 75mg/d
not recommended by most international AF guidelines due to inferior efficacy vs. OACs with similar risk of major bleeding
Patient's annual risk of ischemic stroke+thromboembolism with ASA + clopidogrel:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):
warfarin INR 2-3
Patient's annual risk of ischemic stroke+thromboembolism with warfarin INR 2-3:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):
dabigatran 110mg twice daily
Patient's annual risk of ischemic stroke+thromboembolism with dabigatran 110mg twice daily:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):
dabigatran 150mg twice daily
Patient's annual risk of ischemic stroke+thromboembolism with dabigatran 150mg twice daily:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):
rivaroxaban 20mg once daily
Patient's annual risk of ischemic stroke+thromboembolism with rivaroxaban:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):
apixaban 5mg twice daily
Patient's annual risk of ischemic stroke+thromboembolism with apixaban:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):
edoxaban 30mg once daily
Patient's annual risk of ischemic stroke+thromboembolism with edoxaban 30mg once daily:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):
edoxaban 60mg once daily
Patient's annual risk of ischemic stroke+thromboembolism with edoxaban 60mg once daily:
Relative risk reduction:
Absolute risk reduction:
Chance of benefit per year:
Patient's annual risk of major bleed:
Chance of major bleeding per year on therapy (vs. no therapy):
Strokes prevented per major bleed caused (Net Clinical Benefit):