Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

Measure Specification

A high risk for stroke or systemic embolism is about 2% per year, and all the DOAC trials (Re-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy]; ROCKET AF [Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation]; ARISTOTLE; and ENGAGE AF-TIMI 48 [Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation – Thrombolysis in Myocardial Infarction 48]) included patients with this level of risk.

Patients at intermediate risk (1%-2%/y) can also benefit from anticoagulation, and the RE-LY and ARISTOTLE trials included this population. Stroke risk scores applied to cohorts give different stroke rates, and therefore any score should be viewed as only an estimate of true risk; in addition, some scores used stroke, while others used thromboembolic events.

Nonetheless, it is practical to use a validated risk score, such as CHA2DS2-VASc, ATRIA, or GARFIELD-AF. Future research may yield improved risk scores that refine how to incorporate risk modifiers, such as female sex and other parameters such as AF burden. Anticoagulation has also been shown to be superior to antiplatelet therapy to reduce stroke risk.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation (ACC/AHA/ACCP/HRS, 2024) 1. For patients with AF and an estimated annual thromboembolic risk of ≥2% per year (e.g., CHA2DS2- VASc score of ≥2 in men and ≥3 in women), anticoagulation is recommended to prevent stroke and systemic thromboembolism. (Class 1, Level of Evidence: A) 2.

For patients with AF receiving warfarin (excludes patients with mechanical valves), a target INR between 2 and 3 is recommended, as well as optimal management of drug-drug interactions, consistency in vitamin K dietary intake, and routine INR monitoring to improve time in therapeutic range and to minimize risks of preventable thromboembolism or major bleeding.

(Class 1, Level of Evidence: B-R). 3. In patients with rheumatic mitral stenosis or mitral stenosis of moderate or greater severity and history of AF, long-term anticoagulation with warfarin is recommended over DOACs, independent of the CHA2DS2-VASc score to prevent cardiovascular events, including stroke or death. (Class 1, Level of Evidence B-R).

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once.