Atrial Fibrillation — Anticoagulation Decision Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Valvular status
   Mechanical valve or moderate–severe mitral stenosis (valvular AF)? (A mechanical heart valve or moderate–severe (rheumatic) mitral stenosis defines 'valvular AF', in which DOACs are contraindicated.)
   • Yes (mechanical valve / moderate–severe MS) → Valvular AF → warfarin
   • No (non-valvular AF) → CHA2DS2-VASc annual stroke risk
2. [End] Valvular AF → warfarin
   Anticoagulate with warfarin (INR target per valve type/position); DOACs are contraindicated with mechanical valves and moderate–severe mitral stenosis. Monitor INR regularly and assess bleeding and adherence.
3. [Decision] CHA2DS2-VASc annual stroke risk
   Which CHA2DS2-VASc band? (Points: CHF 1 · hypertension 1 · age ≥75 = 2 · diabetes 1 · stroke/TIA/thromboembolism = 2 · vascular disease 1 · age 65–74 = 1 · female sex 1. The 2023 guideline decides by annual stroke risk: men ≥2 / women ≥3 → ≥2%/yr; men 1 / women 2 → 1–<2%/yr; men 0 / women 1 → <1%/yr.)
   • Men ≥2 / women ≥3 (≥2%/yr) → Anticoagulation recommended (Class 1)
   • Men 1 / women 2 (1–<2%/yr) → Anticoagulation may be considered (Class 2a)
   • Men 0 / women 1 (<1%/yr) → Anticoagulation not needed for now
4. [End] Anticoagulation recommended (Class 1)
   Oral anticoagulation is recommended. A DOAC (apixaban / rivaroxaban / dabigatran / edoxaban, dosed for renal function, weight, age and interacting drugs) is preferred over warfarin. Use HAS-BLED to identify and correct modifiable bleeding risk factors (uncontrolled hypertension, labile INR, concomitant antiplatelet/NSAID, alcohol excess) rather than to withhold anticoagulation.
5. [End] Anticoagulation may be considered (Class 2a)
   Anticoagulation is reasonable. Combine stroke-risk modifiers (AF burden, persistent/permanent AF, obesity, eGFR <45, left-atrial enlargement, poorly controlled hypertension, etc.) with patient preference in shared decision-making; most patients still benefit, with a DOAC preferred.
6. [End] Anticoagulation not needed for now
   Low stroke risk (<1%/yr) — oral anticoagulation generally not needed. Reassess periodically (increasing age or new risk factors can change the risk band).

Source guidelines & references

• 2023 ACC/AHA/ACCP/HRS Guideline for the diagnosis and management of atrial fibrillation. Circulation 2024 · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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