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

Chest: The Journal of Circulation, Respiration and Related Systems

Amitava Banerjee^2¹  Lisa Moores^12^1,13  Ramiz Fargo^5^1,15  Chern en Chiang^4^2,27  Ben Freedman^6^3,39  Deirdre A. Lane^7^4,40  Gregory Y.H. Lip^1^4,42  Christian T. Ruff^8^5,58  Mintu Turakhia^9^5,59  Sheena Patel^11^6,62  Giuseppe Boriani^3^6,63  David Werring^10^6,67 

[1]Affiliate Assistant Professor, University of South Florida, Tampa, FL Adjunct Professor, Barry University School of Law, Orlando, FL. Dr. Friedman is Associate Professor of Psychological Medicine, University of Auckland Staff Psychiatrist, Mason Clinic, Auckland Regional Forensic Psychiatry Services, Auckland, New Zealand the Philip Resnick Professor of Forensic Psychiatry, Case Western Reserve University, Cleveland, OH. Dr. Jain is a Forensic Psychiatry Research Fellow, Columbia University and New York State Psychiatric Institute, New York, NY. Dr. Wagoner is Assistant Professor, University of South Florida College of Medicine, Tampa, FL. Portions of this article were presented at the 2017 American Psychiatric Association Annual Meeting, May 20–24, 2017, in San Diego, CA.^2

[2]Bayer (South East Asia) Pte Ltd, Singapore^49

[3]CNRS, UMR_7210, Paris F-75012, France^30

[4]Centre for International Health, University of Bergen, Bergen, Norway^58

[5]Department of Medicine, Kuala Lumpur, Malaysia^43

[6]Department of Neurology, Jakarta, Indonesia^41

[7]Department of Surgery (Ophthalmology), The University of Melbourne, Victoria, Australia^33

[8]Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Eye Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China^24

[9]Liverpool Centre for Cardiovascular Science, University of Liverpool, and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark^62

[10]Neurology Department, Ho Chi Minh City, Vietnam^47

[11]Novena Heart Centre, Singapore^45

[12]Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Australia^16

[13]Ophthalmology, Department of Surgery, University of Melbourne^12

[14]Philippine Heart Center, Quezon City, Philippines^38

[15]Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia^5

[16]Royal Victorian Eye and Ear Hospital, Melbourne, Australia^13

[17]UPMC Univ Paris 06, UMR_S 968, Institut de la Vision, Paris F-75012, France^29

[18]Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia^51

[19]Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China^26

[20]Brien Holden Vision Institute and School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia^18

[21]Busselton Population Medical Research Institute, WA, Australia^56

[22]CHEST, Glenview, IL^72

[23]Cardiology Clinical Academic Group St. George's, University of London and Imperial College, London, United Kingdom^50

[24]Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena University Hospital, Modena, Italy^64

[25]Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA^69

[26]Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital^32

[27]Centre for Eye Research Australia^4

[28]Centre for Food and Allergy Research, Murdoch Children’s Research Institute, Parkville, VIC, Australia^52

[29]Chang Gung Memorial Hospital, Taoyuan, Taiwan^36

[30]Chang Gung University^37

[31]Children's University Hospital, Technological University Dublin, Dublin, Ireland^15

[32]Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia^42

[33]Department of Anatomy and Neuroscience, The University of Melbourne, Melbourne, Victoria, Australia^31

[34]Department of Medicine, Stanford University School of Medicine, Stanford, CA^70

[35]Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway^60

[36]Department of Ophthalmology, Medical Faculty Mannheim of the Ruprecht-Karis-University Heidelberg, Mannheim, Germany^17

[37]Department of Ophthalmology, Xiang'an Hospital of Xiamen University^23

[38]Department of Psychology, Guangdong Provincial Key Laboratory of Social Cognitive Neuroscience and Mental Health, Guangdong Provincial Key Laboratory of Brain Function and Disease, Sun Yat-sen University, Guangzhou, China^14

[39]Department of Surgery (Ophthalmology), The University of Melbourne, Parkville, Victoria, Australia^6

[40]Division of Optometry and Visual Sciences, School of Health Sciences, City, University of London, United Kingdom^7

[41]Division of Pulmonary and Critical Care, Department of Internal Medicine, Riverside University Medical Center, Moreno Valley, CA, and Division of Pulmonary, Critical Care, Hyperbaric, and Sleep Medicine, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA^66

[42]Dr. Cooke is Associate Professor, University of Florida College of Medicine, Gainesville, FL. Dr. Hall is Assistant Professor of Psychiatry, University of Central Florida College of Medicine^1

[43]Faculty of Medicine, Thammasat University^40

[44]General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan^65

[45]Heart Research Institute/Charles Perkins Centre, University of Sydney and Department of Cardiology Concord Hospital, University of Sydney, Sydney, Australia^67

[46]INSERM, U968, Paris, F-75012, France^28

[47]Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark^68

[48]Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom^61

[49]Institute of Child Health, University College London and Great Ormond Street Hospital for Children, London, United Kingdom^20

[50]Institute of Health Informatics, University College London, London, United Kingdom^63

[51]Korea University Medical Centre, Seoul, South Korea^34

[52]Mount Elizabeth Novena Specialist Centre^46

[53]National Eye Institute, National Institutes of Health, Bethesda, Maryland, United States^21

[54]National Institute of Fundamental Studies, Kandy, Sri Lanka^53

[55]National Taiwan University Hospital, Taipei, Taiwan^35

[56]National University of Malaysia Medical Centre^44

[57]PathWest Laboratory Medicine of West Australia, Perth, WA, Australia^54

[58]Pediatric Ophthalmology and Adult Strabismus Department, Singapore National Eye Centre (SNEC), Singapore^8

[59]Pediatric Ophthalmology and Strabismus Department, KK Women's and Children's Hospital (KKH), Singapore^9

[60]Pham Ngoc Thach Medical University^48

[61]Quinze-Vingts National Ophthalmology Hospital, Paris and Versailles Saint-Quentin-en-Yvelines University, Versailles, France^27

[62]School of Art and Design, Guangdong University of Technology, Guangzhou, China^11

[63]School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia^3

[64]School of Population and Global Health and School of Pathology and Laboratory Medicine, The University of Western Australia, WA, Australia^55

[65]School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia^57

[66]School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia^59

[67]State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China^10

[68]Stroke Excellence Center, Pathum Thani, Thailand^39

[69]Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, University College Hospitals NHS Foundation Trust, London, United Kingdom^71

[70]The Vitreous, Retina, Macula Consultants of New York and the LuEsther T. Mertz Retina Research Center, Manhattan Eye, Ear, and Throat Hospital, New York, New York, United States^22

[71]Tokyo Medical and Dental University, Tokyo, Japan^19

[72]Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, MD^73

[73]Xiamen University Affiliated Xiamen Eye Center, Xiamen, Fujian, China^25

关键词: antithrombotic therapy;    atrial fibrillation;    evidence-based medicine;    guidelines;    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 Echocardiography;    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 Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery;    CAA;    cerebral amyloid angiopathy;    CHA2DS2-VASc;    congestive heart failure;    hypertension;    age ≥75 (doubled);    diabetes;    stroke (doubled)-vascular disease;    age 65-74 and sex category (female);    CHADS2;    congestive heart failure;    hypertension;    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 undetermined source;    GRADE;    Grading of Recommendations;    Assessment;    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 concomitantly (1 point each);    HEMORR2HAGES;    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 hemorrhage;    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 Randomized Evaluation of the Watchman LAA Closure Device In Patients 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;    randomized 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;    Randomized Evaluation of Long-term Anticoagulant Therapy with Dabigatran Etexilate;    RE-VERSE AD;    Reversal Effects of Idarucizumab 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;   

DOI  :  10.1016/j.chest.2018.07.040

学科分类：呼吸医学

来源: American College of Chest Physicians

【 摘 要 】

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, CHA₂DS₂-VASc [congestive heart failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)] 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 CHA₂DS₂-VASc stroke risk factors. For patients with a single non-sex CHA₂DS₂-VASc 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, CHA₂DS₂-VASc ≥ 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 non-vitamin K antagonist oral anticoagulant drug rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range > 70%. Attention to modifiable bleeding risk factors (eg, uncontrolled BP, labile international normalized ratios, concomitant use of aspirin or nonsteroidal antiinflammatory drugs in an anticoagulated patient, alcohol excess) should be made at each patient contact, and HAS-BLED (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile international normalized ratio, elderly (0.65), drugs/alcohol concomitantly [1 point each]) 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-sex CHA₂DS₂-VASc stroke risk factor(s).

【 授权许可】

CC BY