Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report.

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 (e.g., CHA2DS2VASc 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 CHA2DS2VASc stroke risk factors. For patients with a single non-sex CHA2DS2VASc 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, CHA2DS2VASc ≥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 NOAC rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a TTR >70%. Attention to modifiable bleeding risk factors (eg. uncontrolled blood pressure, labile INRs, concomitant use of aspirin or NSAIDs in an anticoagulated patient, alcohol excess) should be made at each patient contact, and HAS-BLED 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-gender CHA2DS2VASc stroke risk factor(s).