The American College of Chest Physicians released updated guidelines last week on antithrombotic therapy in patients with atrial fibrillation.
The guidelines are based on systematic reviews and meta-analyses of the literature published since development of the previous guidelines, which were published in 2012. Overall quality of the evidence was assessed by using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach, and recommendations were finalized based on the consensus of the expert panel. The guidelines were published Aug. 22 by CHEST and are available free of charge online.
The guidelines include 60 recommendation statements for patients at varying levels of stroke risk and for several clinical scenarios in the areas of stroke risk, bleeding risk, antithrombotic therapy and other methods of stroke prevention, adjusted-dose oral vitamin K antagonist (VKA) therapy, and management of bleeding on oral anticoagulation, among other topics. In a press release, the American College of Chest Physicians identified the following as key recommendations that differed from previous guidelines:
- No antithrombotic therapy is suggested in patients with atrial fibrillation without valvular heart disease, including those with paroxysmal atrial fibrillation who are at low stroke risk as determined by standardized risk assessment (i.e. CHA2DS2-VASc score).
- For patients who have one non-sex CHA2DS2-VASc stroke risk factor and for patients who are at high risk for stroke, oral anticoagulation is suggested rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel.
- When oral anticoagulation is recommended or suggested, the guidelines suggest using a novel oral anticoagulant (NOAC) rather than adjusted-dose VKA therapy. When VKA therapy is used, it is important to aim for good-quality anticoagulation control with a time in therapeutic range that is greater than 70%.
- Modifiable bleeding risk factors should be assessed with the HAS-BLED score at every patient contact, and patients considered high-risk, defined as those with a score of 3 or higher, can be identified for earlier review and follow-up visits.
Regarding surgical procedures and interventions, the guidelines suggest preoperative management without bridging for patients with atrial fibrillation who are taking warfarin and do not have a high risk for thromboembolism or a mechanical valve. In patients with atrial fibrillation taking antithrombotic prophylaxis with warfarin who have a high risk for thromboembolism or who do have a mechanical valve, preoperative management with bridging is suggested. Preoperative management without bridging is suggested in patients with atrial fibrillation who are taking a NOAC for antithrombotic prophylaxis.
The guideline authors stressed that atrial fibrillation should not be considered in isolation or at a single stage, such as detection, prevention, or treatment, and noted that although most patients with the disorder die of cardiac causes, most interventions focus on stroke prevention. They called for “a more holistic approach” that considers comorbidities and cross-disease sequelae across primary and secondary care.