Anticoagulation in Atrial Fibrillation: Contraindications and Considerations

Absolute Contraindications to Anticoagulation

Patients with atrial fibrillation should not be anticoagulated if they have absolute contraindications to anticoagulation, most commonly active bleeding, recent intracranial hemorrhage, or severe bleeding risk that outweighs stroke prevention benefit, as recommended by the European Society of Cardiology 1, 2
Active bleeding requires immediate interruption of anticoagulation until the bleeding source is identified and resolved, according to the European Heart Journal 1, 2

Clear patient refusal to take oral anticoagulation or documented inability to cope with anticoagulation monitoring is a valid reason to withhold therapy, as stated by the European Heart Journal 3
Direct thrombin inhibitor dabigatran and factor Xa inhibitor rivaroxaban are not recommended in patients with end-stage chronic kidney disease (CrCl <15 mL/min) or on dialysis due to lack of evidence, as recommended by the American College of Cardiology 5

Assessment of bleeding risk should be performed, but bleeding risk scores should NOT be used to decide whether to start or withdraw anticoagulation—they are meant to identify modifiable risk factors, not to withhold therapy, as stated by the European Heart Journal 1, 2
The HAS-BLED score can identify high-risk patients (score >3) who need careful monitoring, but this should prompt caution and regular review, not automatic withholding of anticoagulation, according to the European Heart Journal 3
Bleeding risk with aspirin should be considered similar to warfarin, especially in the elderly, so aspirin is not a "safer" alternative in high bleeding risk patients, as recommended by the European Heart Journal 3

For surgical or diagnostic procedures with bleeding risk, anticoagulation may be interrupted temporarily (up to 48 hours of subtherapeutic anticoagulation) without bridging therapy in patients without mechanical valves or high thromboembolism risk, as stated by the European Heart Journal 3

In the presence of hemorrhagic stroke, anticoagulation should not be given, as recommended by the European Heart Journal 3
With large cerebral infarction, delaying anticoagulation initiation should be considered due to hemorrhagic transformation risk, according to the European Heart Journal 3
In the absence of hemorrhage, oral anticoagulation should be considered approximately 2 weeks after ischemic stroke, as stated by the European Heart Journal 3

Patients under 60-65 years of age without heart disease or risk factors for thromboembolism (lone AF) do not require anticoagulation, as recommended by the European Society of Cardiology 7
More specifically, patients with a CHA₂DS₂-VASc score of 0 in men can reasonably omit anticoagulation, according to the American Heart Association 6
For nonvalvular AF with CHA₂DS₂-VASc score of 0, it is reasonable to omit antithrombotic therapy, as stated by the American College of Cardiology 5