ABC | Volume 113, Nº1, July 2019

Statement Statement on Antiplatelet Agents and Anticoagulants in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(1):111-134 Figure 2 – Recommendations in relation to pericardioversion anticoagulation in atrial fibrillation. AF: atrial fibrillation; INR: international normalized ratio; LMWH: low-molecular weight heparin; NOAC: new oral anticoagulant; TEE: transesophageal echocardiography; UFH: unfractionated heparin. AF with indication for CV (chemical or electrical) Unstable YES NO AF < 48 h? YES NO UFH or LMWH UFH or LMWH (especially if there is high embolic risk): with or without use of TEE* Strategy without TEE Strategy with TEE Anticoagulation with warfarin until therapeutic INRs or NOAC** for 3 weeks (rivaroxaban, dabigatran, apixaban, or edoxaban) Anticoagulation with warfarin until therapeutic INR 1 or UFH or LMWH or NOAC administered at least 2 hours before cardioversion*** Cardioversion. Evaluate maintaining anticoagulation after cardioversion in patients with high risks of thromboembolism and/or recurrence of AF TEE before cardioversion * In accordance with each healthcare service’s routine ** If adherence to NOAC is questionable: consider performing TEE before cardioversion *** Initiating a heparin (UFH or LMWH) and warfarin simultaneously is an option. The combination of an NOAC with UFH or LMWH is not recommended. TEE without thrombi: proceed to cardioversion. Maintain anticoagulation (warfarin or NOAC) for 4 weeks. Subsequently, reevaluate long-term anticoagulation depending on CHA 2 DS 2 -VASc score and risk of AF recurrence. TEE with thrombus: do not perform cardioversion and proceed to anticoagulation for 3 more weeks with therapeutic INR or 3 weeks of NOAC. Reevaluate new cardioversion subsequently, preceded by a new TEE. suffered a stroke 131 (secondary prevention) or in asymptomatic patients (primary prevention). 111,132,133 The conclusion is, thus, that diagnosis of PFO in a patient with cryptogenic stroke does not establish a causal relation between the two entities, 134 given that the risk attributable to PFO decreases with age and in the presence of risk factors such as systemic arterial hypertension, diabetes mellitus, tobacco use, personal history of transient ischemic attack, or prior stroke. 135 Based on data from a meta-analysis 135 of 12 cohort studies which followed cryptogenic stroke patients, the Risk of Paradoxical Embolism (RoPE) score, which quantifies the risk of PFO-attributable stroke (Table 12), was developed. This study provided evidence that patients with higher scores (with increased risks attributable to PFO as a causal factor of stroke) also had lower risks of stroke recurrence during follow up. In conclusion, the causal relation between PFO and stroke continues to be uncertain, and, even in patients whose stroke mechanism is attributed to PFO/paradoxical embolism, the event recurrence rate is very low (1% to 3% over 2 years in patients with RoPE scores of 9 or 10). 134,135 Some echocardiography characteristics of PFO may be related to greater risks of paradoxical embolism, such as: significant right-left shunt, spontaneous right-left shunt, greater PFO flap mobility, prominent Eustachian valve, presence of Chiari network, and atrial septal aneurysm. 109,136-141 However, some of these characteristics have not been shown to be consistently related to higher rates of embolic events in other studies. 111,132,142-145 6.3. Evidence for the Use of Antiplatelet Agents or Anticoagulants in Patients with Patent Foramen Ovale Given the hypothesis that embolic events related to PFO occur either by paradoxical embolism or embolism of a 125