Antithrombotic Therapy for Atrial Fibrillation CHEST Guideline and Expert Panel Report Gregory Y. H. Lip, MD; Amitava Banerjee, MD, DPhil; Giuseppe Boriani, MD, PhD; Chern en Chiang, MD, PhD; Ramiz Fargo, MD, FCCP; Ben Freedman, MD, PhD; Deirdre A. Lane, PhD; Christian T. Ruff, MD, MPH; Mintu Turakhia, MD; David Werring, PhD; Sheena Patel, MPH; and Lisa Moores, MD, FCCP 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, CHA 2 DS 2 -VASc [congestive heart failure, hypertension, age $ 75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category 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 Echocardiog- raphy; 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 Tem- porary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery; CAA = cerebral amyloid angiopathy; CHA 2 DS 2 -VASc = congestive heart failure, hypertension, age $75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female); CHADS 2 = congestive heart failure; hyper- tension = 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 unde- termined source; GRADE = Grading of Recommendations, Assess- ment, 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 concom- itantly (1 point each); HEMORR 2 HAGES = 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 hemor- rhage; 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 Ran- domized Evaluation of the Watchman LAA Closure Device In Pa- tients 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 = ran- domized 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 = Ran- domized Evaluation of Long-term Anticoagulant Therapy with Dabigatran Etexilate; RE-VERSE AD = Reversal Effects of Idar- ucizumab 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 AFFILIATIONS: From the Institute of Cardiovascular Sciences, Uni- versity of Birmingham, United Kingdom; Liverpool Centre for Car- diovascular 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 (Dr Lip); Institute of Health Informatics, [ Evidence-Based Medicine ] chestjournal.org 1121
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