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

Lip, GYH; Banerjee, A; Boriani, G; Chiang, CE; Fargo, R; Freedman, B; Lane, DA; ... Moores, L; + view all (2018) Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest , 154 (5) pp. 1121-1201. 10.1016/j.chest.2018.07.040. Green open access

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Abstract

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 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).

Type: Article
Title: Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report
Location: United States
Open access status: An open access version is available from UCL Discovery
DOI: 10.1016/j.chest.2018.07.040
Publisher version: https://doi.org/10.1016/j.chest.2018.07.040
Language: English
Additional information: This version is the author accepted manuscript. For information on re-use, please refer to the publisher’s terms and conditions.
UCL classification: UCL > Provost and Vice Provost Offices
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > UCL Queen Square Institute of Neurology
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > UCL Queen Square Institute of Neurology > Brain Repair and Rehabilitation
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Pop Health Sciences > Institute of Health Informatics
URI: http://discovery.ucl.ac.uk/id/eprint/10055161
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