Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
BACKGROUND
The risk of stroke varies considerably across different groups of patients with atrial fibrillation (AF). Antithrombotic prophylaxis for stroke is associated with an increased risk of bleeding. 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
We used the methods described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement.


RESULTS
For patients with nonrheumatic AF, including those with paroxysmal AF, who are (1) at low risk of stroke (eg, CHADS(2) [congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack] score of 0), we suggest no therapy rather than antithrombotic therapy, and for patients choosing antithrombotic therapy, we suggest aspirin rather than oral anticoagulation or combination therapy with aspirin and clopidogrel; (2) at intermediate risk of stroke (eg, CHADS(2) score of 1), we recommend oral anticoagulation rather than no therapy, and we suggest oral anticoagulation rather than aspirin or combination therapy with aspirin and clopidogrel; and (3) at high risk of stroke (eg, CHADS(2) score of ≥ 2), 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 dabigatran 150 mg bid rather than adjusted-dose vitamin K antagonist therapy.


CONCLUSIONS
Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF at high risk of stroke (CHADS(2) score of ≥ 2). At lower levels of stroke risk, antithrombotic treatment decisions will require a more individualized approach.
Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
John J
JJ
You
Department of Medicine, General Medicine Division, Massachusetts General Hospital, Boston, MA; Harvard Medical School, and Clinical Epidemiology Unit, General Medicine Division, Massachusetts General Hospital, Boston, MA.
Daniel E
DE
Singer
School of Pharmacy, University of Kansas Medical Center, Kansas City, KS.
Patricia A
PA
Howard
University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, England.
Deirdre A
DA
Lane
Department of Clinical Medicine, Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH.
Mark H
MH
Eckman
Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA.
Margaret C
MC
Fang
Boston University Medical Center Research Unit, Section of General Internal Medicine, Boston, MA.
Elaine M
EM
Hylek
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Sam
S
Schulman
Comprehensive Clinical Research Unit, Division of Research, Kaiser Permanente Northern California, Oakland, CA.
Alan S
AS
Go
Decision Resources Inc, London, England.
Michael
M
Hughes
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Frederick A
FA
Spencer
Section of Non-invasive Cardiac Imaging, Beth Israel Deaconess Medical Center, Boston, MA.
Warren J
WJ
Manning
The Cardiovascular Institute, Mount Sinai Medical Center, New York, NY.
Jonathan L
JL
Halperin
University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, England. Electronic address: g.y.h.lip@bham.ac.uk.
Gregory Y H
GYH
Lip
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D000925:Anticoagulants; D001562:Benzimidazoles; D005343:Fibrinolytic Agents; D015091:beta-Alanine; D014812:Vitamin K; D000077144:Clopidogrel; D000069604:Dabigatran; D013988:Ticlopidine; D001241:Aspirin