Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report
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 strok...
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| Published in: | Chest Vol. 154; no. 5; p. 1121 |
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| Main Authors: | , , , , , , , , , , , |
| Format: | Journal Article |
| Language: | English |
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United States
01.11.2018
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| ISSN: | 1931-3543, 1931-3543 |
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| Abstract | 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.
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.
For patients with AF without valvular heart disease, including those with paroxysmal AF, who are at low risk of stroke (eg, CHA
DS
-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 CHA
DS
-VASc stroke risk factors. For patients with a single non-sex CHA
DS
-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, CHA
DS
-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.
Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with ≥1 non-sex CHA
DS
-VASc stroke risk factor(s). |
|---|---|
| AbstractList | 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.BACKGROUNDThe 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.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.METHODSSystematic 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.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.RESULTSFor 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.Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with ≥1 non-sex CHA2DS2-VASc stroke risk factor(s).CONCLUSIONSOral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with ≥1 non-sex CHA2DS2-VASc stroke risk factor(s). 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. 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. For patients with AF without valvular heart disease, including those with paroxysmal AF, who are at low risk of stroke (eg, CHA DS -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 CHA DS -VASc stroke risk factors. For patients with a single non-sex CHA DS -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, CHA DS -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. Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with ≥1 non-sex CHA DS -VASc stroke risk factor(s). |
| Author | Lane, Deirdre A Werring, David Fargo, Ramiz Boriani, Giuseppe Ruff, Christian T Patel, Sheena Freedman, Ben Turakhia, Mintu Chiang, Chern En Moores, Lisa Banerjee, Amitava Lip, Gregory Y H |
| Author_xml | – sequence: 1 givenname: Gregory Y H surname: Lip fullname: Lip, Gregory Y H email: gregory.lip@liverpool.ac.uk organization: Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. Electronic address: gregory.lip@liverpool.ac.uk – sequence: 2 givenname: Amitava surname: Banerjee fullname: Banerjee, Amitava organization: Institute of Health Informatics, University College London, London, United Kingdom – sequence: 3 givenname: Giuseppe surname: Boriani fullname: Boriani, Giuseppe organization: Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena University Hospital, Modena, Italy – sequence: 4 givenname: Chern En surname: Chiang fullname: Chiang, Chern En organization: General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan – sequence: 5 givenname: Ramiz surname: Fargo fullname: Fargo, Ramiz organization: Division of Pulmonary and Critical Care, Department of Internal Medicine, Riverside University Medical Center, Moreno Valley, CA, and Division of Pulmonary, Critical Care, Hyperbaric, and Sleep Medicine, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA – sequence: 6 givenname: Ben surname: Freedman fullname: Freedman, Ben organization: Heart Research Institute/Charles Perkins Centre, University of Sydney and Department of Cardiology Concord Hospital, University of Sydney, Sydney, Australia – sequence: 7 givenname: Deirdre A surname: Lane fullname: Lane, Deirdre A organization: Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark – sequence: 8 givenname: Christian T surname: Ruff fullname: Ruff, Christian T organization: Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA – sequence: 9 givenname: Mintu surname: Turakhia fullname: Turakhia, Mintu organization: Department of Medicine, Stanford University School of Medicine, Stanford, CA – sequence: 10 givenname: David surname: Werring fullname: Werring, David organization: Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, University College Hospitals NHS Foundation Trust, London, United Kingdom – sequence: 11 givenname: Sheena surname: Patel fullname: Patel, Sheena organization: CHEST, Glenview, IL – sequence: 12 givenname: Lisa surname: Moores fullname: Moores, Lisa organization: Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, MD |
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| References | 31174652 - Chest. 2019 Jun;155(6):1309-1311 31174650 - Chest. 2019 Jun;155(6):1308 31174651 - Chest. 2019 Jun;155(6):1309 31174649 - Chest. 2019 Jun;155(6):1307 31174647 - Chest. 2019 Jun;155(6):1306-1307 31174653 - Chest. 2019 Jun;155(6):1311-1312 |
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| Snippet | The risk of stroke is heterogeneous across different groups of patients with atrial fibrillation (AF), being dependent on the presence of various stroke risk... |
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| SubjectTerms | Anticoagulants - administration & dosage Anticoagulants - adverse effects Anticoagulants - classification Atrial Fibrillation - complications Atrial Fibrillation - therapy Catheter Ablation - methods Defibrillators, Implantable Electric Countershock - instrumentation Electric Countershock - methods Hemorrhage - chemically induced Hemorrhage - prevention & control Humans Medication Therapy Management - standards Patient Education as Topic - methods Risk Assessment - methods Risk Factors Stroke - etiology Stroke - prevention & control |
| Title | Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report |
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