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Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only Articles |

Antithrombotic Therapy for Atrial FibrillationAntithrombotic Therapy for Atrial Fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines FREE TO VIEW

John J. You, MD; Daniel E. Singer, MD; Patricia A. Howard, PharmD; Deirdre A. Lane, PhD; Mark H. Eckman, MD; Margaret C. Fang, MD, MPH; Elaine M. Hylek, MD, MPH; Sam Schulman, MD, PhD; Alan S. Go, MD; Michael Hughes, PhD; Frederick A. Spencer, MD; Warren J. Manning, MD; Jonathan L. Halperin, MD; Gregory Y. H. Lip, MD
Author and Funding Information

From the Department of Medicine (Drs You, Schulman, and Spencer) and Department of Clinical Epidemiology and Biostatistics (Dr You), McMaster University, Hamilton, ON, Canada; Department of Medicine (Dr Singer), Harvard Medical School, and Clinical Epidemiology Unit (Dr Singer), General Medicine Division, Massachusetts General Hospital, Boston, MA; School of Pharmacy (Dr Howard), University of Kansas Medical Center, Kansas City, KS; University of Birmingham Centre for Cardiovascular Sciences (Drs Lane and Lip), City Hospital, Birmingham, England; Department of Clinical Medicine (Dr Eckman), Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH; Department of Medicine (Dr Fang), Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA; Boston University Medical Center Research Unit (Dr Hylek), Section of General Internal Medicine, Boston, MA; Comprehensive Clinical Research Unit (Dr Go), Division of Research, Kaiser Permanente Northern California, Oakland, CA; Decision Resources Inc (Dr Hughes), London, England; Section of Non-invasive Cardiac Imaging (Dr Manning), Beth Israel Deaconess Medical Center, Boston, MA; and The Cardiovascular Institute (Dr Halperin), Mount Sinai Medical Center, New York, NY.

Correspondence to: Gregory Y. H. Lip, MD, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, B18 7QH, England; e-mail: g.y.h.lip@bham.ac.uk


Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.

Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Chest. 2012;141(2_suppl):e531S-e575S. doi:10.1378/chest.11-2304
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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, CHADS2 [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, CHADS2 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, CHADS2 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 (CHADS2 score of ≥ 2). At lower levels of stroke risk, antithrombotic treatment decisions will require a more individualized approach.

Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.

2.1.8. For patients with AF, including those with paroxysmal AF, who are at low risk of stroke (eg, CHADS2 [congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack] score = 0), we suggest no therapy rather than antithrombotic therapy (Grade 2B). For patients who do choose antithrombotic therapy, we suggest aspirin (75 mg to 325 mg once daily) rather than oral anticoagulation (Grade 2B) or combination therapy with aspirin and clopidogrel (Grade 2B).

Remarks: Patients who place an exceptionally high value on stroke reduction and a low value on avoiding bleeding and the burden associated with antithrombotic therapy are likely to choose antithrombotic therapy rather than no antithrombotic therapy. Other factors that may influence the choices above are a consideration of patient-specific bleeding risk and the presence of additional risk factors for stroke, including age 65 to 74 years and female gender, which have been more consistently validated, and vascular disease, which has been less well validated (see section 2.1.12). The presence of multiple non-CHADS2 risk factors for stroke may favor oral anticoagulation therapy.

2.1.9. For patients with AF, including those with paroxysmal AF, who are at intermediate risk of stroke (eg, CHADS2 score = 1), we recommend oral anticoagulation rather than no therapy (Grade 1B). We suggest oral anticoagulation rather than aspirin (75 mg to 325 mg once daily) (Grade 2B) or combination therapy with aspirin and clopidogrel (Grade 2B). For patients who are unsuitable for or choose not to take an oral anticoagulant (for reasons other than concerns about major bleeding), we suggest combination therapy with aspirin and clopidogrel rather than aspirin (75 mg to 325 mg once daily) (Grade 2B).

Remarks: Patients who place an exceptionally high value on stroke reduction and a low value on avoiding bleeding and the burden associated with anticoagulant therapy are likely to choose oral anticoagulation rather than antiplatelet therapy. Other factors that may influence the choice among antithrombotic therapies are a consideration of bleeding risk and the presence of additional risk factors for stroke, including age 65 to 74 years and female gender, which have been more consistently validated, and vascular disease, which has been less well validated (see section 2.1.12). The presence of multiple additional non-CHADS2 risk factors for stroke may favor oral anticoagulation therapy.