Guides MDFR

Cardiology

Atrial fibrillation

CCS 2020 guideline is rhythm vs rate strategy and anticoagulation.

Screening

CCS opportunistic
  • CCS Canadian Cardiovascular Society
DecisionGuideline
Who
Opportunistic pulse check ≥65 CCS recommends opportunistic pulse palpation or rhythm assessment in adults ≥65.
  • Confirm irregular pulse with ECG.

CCS 2020 AF opens in a new tab

Diagnose

ECG confirmation
  • INESSS Institut national d'excellence en santé et services sociaux
  • CCS Canadian Cardiovascular Society
DecisionGuideline
Confirm AF
ECG or rhythm strip Irregular pulse alone is not sufficient for diagnosis.

INESSS 2019 GUO Fibrillation (DOAC vs warfarin) opens in a new tabCCS 2020 Atrial Fibrillation guideline hub opens in a new tab

Valvular AF
Mechanical valve or mod-severe MS
  • Warfarin, not DOAC.
  • Other valve disease does not make AF valvular.

INESSS 2019 GUO Fibrillation (DOAC vs warfarin) opens in a new tabCCS 2020 Atrial Fibrillation guideline hub opens in a new tab

Investigate

Stroke risk
  • INESSS Institut national d'excellence en santé et services sociaux
  • CCS Canadian Cardiovascular Society
DecisionGuideline
Stroke risk score
CHADS-65 or CHA₂DS₂-VASc
  • CHADS-65 simplifies age points (all ≥65 get +1).
  • CHA₂DS₂-VASc distinguishes 65–74 vs ≥75.
  • Do not use CHADS2 alone.

MDCalc CHADS-65 opens in a new tabMDCalc CHA2DS2-VASc opens in a new tabINESSS 2019 opens in a new tab

Bleeding risk
HAS-BLED or clinical judgment Calculate bleeding risk to identify modifiable factors, not to withhold anticoagulation.
  • High bleeding risk does not exclude anticoagulation if high stroke risk.

MDCalc HAS-BLED opens in a new tabINESSS 2019 GUO Fibrillation (DOAC vs warfarin) opens in a new tabCCS 2020 Atrial Fibrillation guideline hub opens in a new tab

CKD and eGFR
Cockcroft-Gault for DOAC dosing Use Cockcroft-Gault equation for DOAC dose adjustment, not CKD-EPI.
  • Stage 5 CKD or dialysis: do not routinely anticoagulate, discuss risks/benefits.

INESSS 2019 opens in a new tabCCS 2020 Atrial Fibrillation guideline hub opens in a new tab

Treat

Prefer DOAC
  • INESSS Institut national d'excellence en santé et services sociaux
  • CCS Canadian Cardiovascular Society
DecisionGuideline
Anticoagulation
DOAC preferred over warfarin Usual adult labeled doses below.
  • Reduce for age, weight, creatinine, or CrCl as in CCS 2020 Table 7 and INESSS 2019.
  • Valvular AF: warfarin, not DOAC.

INESSS 2019 GUO (DOAC vs warfarin) opens in a new tabCCS 2020 AF opens in a new tab

Rate vs rhythm control
Rate or rhythm individualized Rate control or rhythm control selected based on symptoms, age, comorbidities.
  • Both strategies require anticoagulation when indicated.
  • INESSS 2019 is silent on strategy.

CCS 2020 AF opens in a new tab

Usual adult DOAC
DrugDoseDuration
Apixaban5 mg PO BIDOngoing
Rivaroxaban20 mg PO DIE with foodOngoing
Dabigatran150 mg PO BIDOngoing
Edoxaban60 mg PO DIEOngoing

Special groups

Pregnancy, CKD stage 5
  • INESSS Institut national d'excellence en santé et services sociaux
  • CCS Canadian Cardiovascular Society
DecisionGuideline
Pregnancy
Refer No warfarin first trimester or 2–4 weeks before delivery.

INESSS 2019 GUO Fibrillation (DOAC vs warfarin) opens in a new tabCCS 2020 Atrial Fibrillation guideline hub opens in a new tab

CKD stage 5 or dialysis
Do not routinely anticoagulate Discuss individual stroke and bleeding risks with patient and specialist.

INESSS 2019 opens in a new tabCCS 2020 Atrial Fibrillation guideline hub opens in a new tab

Reviewed 31 August 2026 against the official sources below.

Sources

Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.

INESSS 2019 GUO Fibrillation (DOAC vs warfarin) opens in a new tab
CCS 2020 Atrial Fibrillation guideline hub opens in a new tab