Chest
Volume 154, Issue 5, November 2018, Pages 1121-1201
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Evidence-Based Medicine
Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report

https://doi.org/10.1016/j.chest.2018.07.040Get rights and content

Background

The risk of stroke is heterogeneous across different groups of patients with atrial fibrillation (AF), being dependent on the presence of various stroke risk factors. We provide recommendations for antithrombotic treatment based on net clinical benefit for patients with AF at varying levels of stroke risk and in a number of common clinical scenarios.

Methods

Systematic literature reviews were conducted to identify relevant articles published from the last formal search perfomed for the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition). The overall quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted, voted on, and revised until consensus was reached.

Results

For patients with AF without valvular heart disease, including those with paroxysmal AF, who are at low risk of stroke (eg, CHA2DS2-VASc [congestive heart failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)] score of 0 in males or 1 in females), we suggest no antithrombotic therapy. The next step is to consider stroke prevention (ie, oral anticoagulation therapy) for patients with 1 or more non-sex CHA2DS2-VASc stroke risk factors. For patients with a single non-sex CHA2DS2-VASc stroke risk factor, we suggest oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel; and for those at high risk of stroke (eg, CHA2DS2-VASc ≥ 2 in males or ≥ 3 in females), we recommend oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel. Where we recommend or suggest in favor of oral anticoagulation, we suggest using a non-vitamin K antagonist oral anticoagulant drug rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range > 70%. Attention to modifiable bleeding risk factors (eg, uncontrolled BP, labile international normalized ratios, concomitant use of aspirin or nonsteroidal antiinflammatory drugs in an anticoagulated patient, alcohol excess) should be made at each patient contact, and HAS-BLED (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile international normalized ratio, elderly (0.65), drugs/alcohol concomitantly [1 point each]) score used to assess the risk of bleeding where high risk patients (≥ 3) should be reviewed and followed up more frequently.

Conclusions

Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with ≥1 non-sex CHA2DS2-VASc stroke risk factor(s).

Key Words

antithrombotic therapy
atrial fibrillation
evidence-based medicine
guidelines

Abbreviations

ABC
Atrial fibrillation Better Care
ACS
acute coronary syndrome
ACTIVE W
Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events
ACUTE
Assessment of Cardioversion Using Transesophageal Echocardiography
AFFIRM
Atrial Fibrillation Follow-up Investigation of Sinus Rhythm Management
AHRE
atrial high-rate episode
aPTT
activated partial thromboplastin time
ARISTOTLE
Apixaban for Reduction of Stroke and Other Thromboembolic Events in Atrial Fibrillation
ATRIA
Anticoagulation and Risk Factors in Atrial Fibrillation
AVERROES
Apixaban Versus Acetylsalicylic Acid (ASA) to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment
BRIDGE
Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery
CAA
cerebral amyloid angiopathy
CHA2DS2-VASc
congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)
CHADS2
congestive heart failure
hypertension
age
diabetes
stroke (doubled)
CIED
cardiac implanted electrical device
CKD
chronic kidney disease
CMB
cerebral microbleed
COI
conflicts of interest
CrCl
creatinine clearance
DAPT
dual antiplatelet therapy
ESUS
embolic stroke of undetermined source
GRADE
Grading of Recommendations, Assessment, Development, and Evaluation
HAS-BLED
hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile INR, elderly (0.65), drugs/alcohol concomitantly (1 point each)
HEMORR2HAGES
hepatic or renal disease, ethanol abuse, malignancy, older, reduced platelet count/function, hypertension, anemia, genetic factors, excessive fall risk, and stroke
HF
heart failure
HR
hazard ratio
ICH
intracranial hemorrhage
INR
international normalized ratio
LAA
left atrial appendage
LAAO
left atrial appendage occlusion
LMWH
low-molecular-weight heparin
MI
myocardial infarction
MOST
Atrial Diagnostics Ancillary Study of the Mode Selection Trial
NOAC
non-vitamin K antagonist oral anticoagulant drug
OAC
oral anticoagulant
o.d.
omni die (every day)
PAD
peripheral arterial disease
PCC
prothrombin complex concentrate
PCI
percutaneous coronary intervention
PREVAIL
Prospective Randomized Evaluation of the Watchman LAA Closure Device In Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy trial
PROTECT AF
Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation
RCT
randomized controlled trial
RE-ALIGN
Randomized, Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients after Heart Valve Replacement
RE-LY
Randomized Evaluation of Long-term Anticoagulant Therapy with Dabigatran Etexilate
RE-VERSE AD
Reversal Effects of Idarucizumab on Active Dabigatran
ROCKET AF
Rivaroxaban Once daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation
RR
risk ratio
SPAF-I
Stroke Prevention in AF
TEE
transesophageal echocardiography
TIA
transient ischemic attack
t.i.d.
ter in die (three times daily)
TT
thrombin time
TTE
transthoracic echocardiography
TTR
time in therapeutic range
UFH
unfractionated heparin
VKA
vitamin K antagonist

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DISCLAIMER: CHEST Guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which should always be sought for any medical condition. The complete disclaimer for this guideline can be accessed at: http://www.chestnet.org/Guidelines-and-Resources

FUNDING/SUPPORT: This study was funded in total by internal funds from the American College of Chest Physicians.

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