What factors may play role in your decision whether to anticoagulate or not patients with subclinical AF? I am interested in gathering a sense of what different electrophysiologists actually have been doing in real life given the lack of clear consensus.
It would depend on the CHA2DSVASC and the HASBLED scores. If the first one is one or more and the HASBLED is low I would initiate anticoagulation. If the second is moderate or even high but the CHADS is low (0) I would only give aspirin. Usually the latter would happen in young people. Hope I have been useful.
As far as I know, there is currently no clear evidence for aspirin for anticoagulation / antithrombotic treatment in AF patients. Either vitamin K antagonists or NOACs should be started in patients with a CHA2DS2-VASc-Score of 2 or more. If CHA2DS2-VASc-Score is 1, weigh the individual bleeding risk (by using the HASBLED score) against the individual thrombotic risk (using additional values like biomarkers). Regarding the question of vitamin K antagonists or NOACs, NOACs show a lower bleeding complication risk. Bear in mind that those scores have mainly not been developed in patients treated with NOACs - future research is needed to fully answer your question. I hope this is at least to some extent helpful!
Kind regards
If the question is about anticoagulant indication for paroxysmal (detected by continuously monitoring devices) vs. persistent/permanent AF or symptomatic (palpitation, stroke) vs. asymptomatic AF, then the indication is based on CHA2DS2-VASc and HASBLED scores regardless of subtype or symptomatology.
According to 2016 ESC guideline for the management of AF, I consider the duration of AHRE first. If AHRE at least 6 minutes, I will consider CHA2DS2-VASc score to whether the patients need the indication of OACs. If those are high risk of stroke, I consider their resting ECG or ambulatory ECG for documentation of AF. If no any documentation of AF, I need to review EGM from the device and probability for AF occurrence.
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