ACE Clinical Guidances (ACGs)

[also known as Appropriate Care Guides]

ACGs provide concise, evidence-based recommendations to inform specific areas of clinical practice and serve as a common starting point nationally for clinical decision-making. ACGs are underpinned by a wide array of considerations contextualised to Singapore, based on best available evidence at the time of development. Each ACG is developed in collaboration with a multidisciplinary group of local experts representing relevant specialties and practice settings. ACGs are not exhaustive of the subject matter and do not replace clinical judgement.

Published on 20 Nov 2017 | Under Review
Last Updated on 20 Nov 2017
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This Appropriate Care Guide (ACG) highlights the importance of appropriate anticoagulation and provides clinicians with recommendations on when to initiate anticoagulation, how to select between warfarin and non-vitamin K antagonists, and appropriate follow-up and monitoring of patients.

A supplementary guide on how to switch between agents has also been provided.

This ACG is currently under review to be updated based on the latest evidence where relevant.

Download the PDF below to access the full ACG.

Key Messages
1. Offer anticoagulation to patients with atrial fibrillation (AF) and a modified CHA2DS2VASc score of 2 or more.
2. Choose warfarin or a non-vitamin K antagonist oral anticoagulant (NOAC), based on patient, drug and disease factors.
  • Warfarin and NOACs are comparable in preventing AF-related stroke and systemic embolism. NOACs are also known as direct oral anticoagulants (DOACs).
  • Warfarin is the only drug with proven safety and efficacy in patients with AF and mechanical heart valves or moderate to severe mitral stenosis.
  • Use NOACs only in patients with creatinine clearance 30 mL/min or more (using Cockcroft-Gault formula).
3. Review oral anticoagulation at least annually and when patients' clinical circumstances change.
4. Use antiplatelet agents selectively based on risk stratification when anticoagulation is contraindicated. Antiplatelet agents are inferior to anticoagulants for preventing AF-related strokes.


Oral anticoagulation for atrial fibrillation (Nov 2017) Supplementary guide - Switching between anticoagulants (May 2018)