Robert Hatala
The avalanche of new knowledge from large landmark clinical trials on management of atrial fibrillation, mainly on prevention of thromboembolism, was in 2012 the main reason for a quick focused update (already after 2 years) of the 2010 ESC guidelines. Clinically relevant key changes in recommended thromboprophylactic strategy can be summarized as follows: 1. Oral anticoagulation therapy is indicated in majority of patients with non-valvular atrial fibrillation. The exception are patients younger than 65 years (both men and women) with idiopathic (“lone”) atrial fibrillation without cardiovascular comorbidities. 2. For the assessment of thromboembolic risk it is recommended to use the scoring system CHA2DS2-VASc, which reliably identifies patients with a low risk of events (CHA2DS2-VASc=0). 3. Acetylsalicylic acid does not offer safe and effective thromboprophylaxis. Its administration (possibly also in combination with clopidogrel) is acceptable in patients refusing anticoagulation and/or in patients indicated for a dual antiplatelet treatment in whom adding oral anticoagulation would unacceptably increase the risk of serious bleeding. 4. In high-risk and especially old patients the bleeding risk can be assessed by the HAS-BLED scoring system. However, this should serve as a guide for minimization of bleeding risk and not as a tool for contraindication to oral anticoagulation treatment. 5. Besides warfarin, new, more effective and safer drugs (dabigatran, rivaroxaban, apixaban) are currently available in clinical practice. In accordance with the country specific legislation for their prescription they should be preferred as the thromboprophylactic agents of the first choice.