Managing stroke risk in specific populations often requires a tailored approach. The HCP must weigh the risks and benefits of the different types of management strategies with each patient, and there are many “gray” areas for which no solid evidence base is available.

This case-based activity will address what to do when ‘special situations’ arise and will examine the management of stroke risk in various patient populations in the context of surgery, acute coronary syndrome, AF ablation, and after a major bleeding event.

Following this activity, the learner can participate in an 18-question self-assessment examination.

• Cite the indications for anticoagulation for stroke prevention for patients with atrial fibrillation
• Compare and contrast the indications and contraindications of either warfarin or a direct oral anticoagulant (DOAC) in a variety of patient populations
• Determine when a patient with AF should be referred for specialty care
• Calculate a CHA₂DS₂-VASc score and interpret the results in a variety of patient populations
• Apply shared decision-making to determine whether or not to prescribe anticoagulation based on CHA₂DS₂-VASc score
• Determine fall risks and benefits of anticoagulation
• Manage a patient’s anticoagulation bridging strategy when an interruption is necessary due to surgery or other cause
• Determine when to resume anticoagulation after overt gastrointestinal bleed (GIB)
• Discuss FDA approved reversal agents for DOACs with patients with atrial fibrillation
• Summarize indications for DOAC dosage adjustment
• Differentiate the potential impact of bleeding risk compared to stroke risk when considering CHA₂DS₂-VASc and HAS-BLED scores

Accreditation Statement
The Heart Rhythm Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians AMA Designation Statement
The Heart Rhythm Society designates this internet enduring activity for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Statement 

Successful completion of this ACE activity, which includes participation in the evaluation component, enables the participant to earn up to 2 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of ACE credits claimed for the activity. It is the ACE activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Royal College of Physicians and Surgeons of Canada MOC Recognition Statement
Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME’s “ACE in Support of MOC” program in Section 3 of the Royal College’s MOC Program.

Other Credit Available
A Credit Certificate (for physicians) or Certificate of Participation (for non-physicians) will be provided to individuals seeking credit from the following organizations which accept AMA PRA Category 1 Credit(s)™. Note that participants are advised to contact their certifying body for specific information regarding credit submissions:
·         American Academy of Family Physicians (AAFP) (for elective credit)
·         American Academy of Nurse Practitioners Certification Board (AANPCB)
·         American Academy of Physician Assistants (AAPA)
·         American Nurses Credentialing Center (ANCC)
·         American Osteopathic Association (AOA) (for Category 2 credit)
·         Committee on Accreditation of Continuing Medical Education (Canada)
·         European Board for Accreditation in Cardiology (EBAC)
·         European CME Credits (ECMEC)
·         German Chambers of Physicians
·         National Society of Genetic Counselors (for Category 2 credit)
·         Oman Medical Specialty Board
·         Qatar Council for Healthcare Practitioners
·         Royal College of Physicians and Surgeons of Canada (RCPSC)

ACE Disclosure Policy

The Heart Rhythm Society is committed to the provision of Accredited Continuing Education (formerly known as Continuing Medical Education (CME)) that is balanced, objective, and evidence based. HRS adheres to the Standards for Integrity and Independence in Accredited Continuing Education of the Accreditation Council for Continuing Medical Education (ACCME) which require that those individuals in a position to control the content of an educational activity (including, but not limited to, planners, faculty, authors, committee members, content reviewers, editors, and staff) disclose all financial relationships with an ACCME-defined ineligible company* within the 24 months prior to the disclosure.

Any individual who refuses to disclose financial relationships is disqualified from participating in HRS ACE-certified activities. Owners and employees of ACCME-defined ineligible companies may have no role in the planning or implementation of ACE activities without a special written exemption from the HRS Chief Learning Officer that will be granted only in specific circumstances that meet ACCME requirements.

Any individual who refuses to disclose financial relationships is disqualified from participating in HRS ACE-certified activities. Owners and employees of ACCME-defined ineligible companies may have no role in the planning or implementation of ACE activities without a special written exemption from the HRS Chief Learning Officer that will be granted only in specific circumstances that meet ACCME requirements.

ACCME Definition:

*An ineligible company is one whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Examples of such organizations include:

• Advertising, marketing, or communication firms whose clients are ineligible companies
• Bio-medical startups that have begun a governmental regulatory approval process
• Compounding pharmacies that manufacture proprietary compounds
• Device manufacturers or distributors
• Diagnostic labs that sell proprietary products
• Growers, distributors, manufacturers or sellers of medical foods and dietary supplements
• Manufacturers of health-related wearable products
• Pharmaceutical companies or distributors
• Pharmacy benefit managers
• Reagent manufacturers or sellers

The Heart Rhythm Society is committed to the provision of Accredited Continuing Education (formerly known as Continuing Medical Education (CME)) that is balanced, objective, and evidence based. HRS adheres to the Standards for Integrity and Independence in Accredited Continuing Education of the Accreditation Council for Continuing Medical Education (ACCME) which require that those individuals in a position to control the content of an educational activity (including, but not limited to, planners, faculty, authors, committee members, content reviewers, editors, and staff) disclose all financial relationships with an ACCME-defined ineligible company within the 24 months prior to the disclosure.

The Heart Rhythm Society takes steps to assure its learners and the public that the content of certified activities is accurate and reliable. The following principles are applied to the process of validating CME content. The content is peer-reviewed to ensure the following:

Fair Balance - that content is balanced among various options available for treatment and not biased toward a particular product or manufacturer.

Patient Treatment Recommendations - that patient treatment recommendations contained in the content are evidence-based, are appropriate for the target audience, and that the patient treatment recommendations contribute to overall improvement in patient care.

Scientific Validity - those scientific studies cited in the activity conform to standards accepted by the scientific community.

Learning Objectives - that the educational content supports the learning objectives of the activity, and that the objectives stated for performance-in-practice are actionable and measurable.

Omissions - that no seminal studies, data, or best evidence are missing