ACCP guidelines for antithrombotics in atrial fibrillation

Reference

Lip GY, Banerjee A, Boriani G, et al. Antithrombotic therapy for atrial fibrillation: CHEST guideline and expert panel report. Chest 2018;154(5):1121-1201.

Synopsis

This is the most recent iteration of the guidelines for the management of antithrombotic therapy from the American College of Chest Physicians. The authors based the guideline on systematic literature reviews, used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach to assess the strength of evidence, and then used a consensus Delphi-like process for drafting the final recommendations. Here are the key takeaway points: (1) Use the CHA₂DS₂-VASc score to assess the risk of stroke. Men with a score of 0 and women with a score of 1 are at low risk for stroke and do not require anticoagulation. (2) Men with a CHA₂DS₂-VASc score of 1 or more and women with a score of 2 or more should be offered anticoagulation. (3) The guidelines recommend direct oral anticoagulants as the preferred agents (rather than vitamin K antagonists) for most patients with newly diagnosed atrial fibrillation, although this decision should be individualized. (4) The guidelines recommend against using aspirin or aspirin plus clopidogrel for antithrombotic prophylaxis for atrial fibrillation. (5) Use the HAS-BLED score to assess bleeding risk; if the score is 3 or higher look for ways to reduce risk, educate about what to watch for regarding bleeding, and consider following up more closely. (6) For patients currently taking warfarin, consider switching to a direct oral anticoagulant if they are in the INR range less than 65% of the time. (7) If patients are also taking aspirin, first make sure they really need it, then use a low dose (75 mg to 100 mg) and treat with a concomitant proton pump inhibitor. There are a total of 60 recommendations, but these are the ones most relevant to primary care practice.