CLINICIAN GUIDE · ANTICOAGULATION & LAA CLOSURE · SECTION 2 OF 3

The anticoagulation patient in clinic

Assess dosing, bleeding concerns, and urgent presentations.

1. Calculate CHA2DS2-VASc

Add the points for the patient’s stroke-risk factors. Count only one age category. Include the female-sex point in the total.

2. Start OAC at the recommended threshold

Men: score 2 or higher
OAC is recommended.

Women: score 3 or higher
OAC is recommended.

When this threshold is met, initiate an appropriate oral anticoagulant unless contraindicated, after reviewing bleeding concerns, renal function, interactions, and dose criteria.

Example: Hypertension (1) + diabetes (1) = 2 in a man. Adding the female-sex point gives 3 in a woman. Both meet the recommended threshold.

Intermediate risk: At 1 in men or 2 in women, OAC is reasonable after individualized discussion. Female sex alone does not justify OAC.

These thresholds apply to clinical AF/flutter. Device-detected episodes and other independent anticoagulation indications require their own assessment.

2023 ACC/AHA/ACCP/HRS AF guideline: anticoagulation recommendations

Check safety and select the appropriate agent

Review CBC, kidney/liver function, weight, age, interactions, adherence, bleeding history, and cost.
Use label-based dosing and the appropriate renal-function calculation. Do not reduce the dose simply because a patient seems frail.
DOACs are generally preferred in eligible AF. Mechanical valves or moderate-or-greater mitral stenosis require a warfarin-based pathway.
Reassess dose, renal function, and bleeding concerns over time.

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Reduce bleeding risk while preserving stroke protection

Review unnecessary aspirin, NSAIDs, alcohol exposure, uncontrolled BP, anemia, and treatable bleeding sources. A bleeding score helps identify concerns; it should not be the sole reason to withhold indicated anticoagulation.

Document the reason, severity, timing, and reversibility of prior bleeding. Recurrent falls need evaluation, not an automatic cancellation of stroke prevention.

LAA clot risk compared with reduced clot formation on prescribed anticoagulation — Anticoagulants reduce risk; they do not eliminate it.

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Recognize an acute problem

Major ongoing bleeding, suspected intracranial hemorrhage, hemodynamic instability, or acute stroke symptoms requires emergency assessment. Activate EMS when appropriate. The hospital team manages interruption, reversal, and restart. For planned procedures, coordinate a written hold/restart plan; avoid independent indefinite discontinuation.

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Clinical references

Adult clinician education · References reviewed October 11, 2026.