An option is to con- sider double therapy the use of an oral antico- agulant plus a P2Y12 inhibitor without aspirin.S7.4-3 If triple therapy is used, efforts may be directed to minimize duration of triple therapy to a period of 4 to 6 weeks, as this is the period of greatest risk of stent thrombosis, especially in patients with ACS, such as ST-segment elevation MI. Use of DAPT alone may be considered for patients with ACS who have AF and a CHA2 -VASc score of 0 to 1, with recon- sideration of the indications for anticoagulation over Whereas Section 4.1.1. provides spe- cific guidance on the presence/absence of stroke risk associated with female sex in the CHA2 -VASc score, the randomized data set referenced in this section on double versus triple therapy in patients undergoing PCI (subset with ACS) does not present the data analysis stratified by sex; therefore, the rec- ommendation is provided in the context of overall -VASc score. The HAS-BLED score can be used to assess bleeding risk in patients for whom an- ticoagulation is being considered.S7.4-17 Urgent direct-current cardioversion is appropriate in patients with ACS presenting with new-onset AF and intractable ischemia, hemodynamic instability, or inade- quate rate control. Intravenous administration of a beta blocker is indicated for rate control in patients with ACS to reduce myocardial oxygen demands. Intrave- nous amiodarone is an appropriate alternative for rate control and may facilitate conversion to sinus rhythm. Digoxin may be considered in those with severe LV dys- function and HF or hemodynamic instability. 