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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e32

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

Synopsis Prevention of stroke is important in patients with AF to maximize survival, health, and QOL. Selection of stroke risk reduction therapy should be guided by the patient’s risk of stroke, risks of bleeding with therapy, and their individual preferences. When considering stroke prevention therapy, the risk of stroke should inform the decision regardless of the pattern of AF (paroxysmal, persistent, long-standing persistent, or permanent). All decisions regarding stroke prevention therapy should be periodically reassessed since a patient’s risk, eligibility, and preferences can change over time. Recommendation-Specific Supportive Text 1.	 Although the risk of stroke and systemic embolism

and all-cause mortality are increased in persons with more persistent forms of AF, selection of stroke prevention therapy should be based on the risk of stroke and not the pattern of AF. Treatment effects with oral anticoagulation are consistent across AF patterns (paroxysmal, persistent, long-standing persistent, or permanent) in trials of stroke prevention therapy.1–3

2 AF is a lifelong condition and, thus, patient char-

acteristics, risk factors, and net clinical benefit can and often will change over time.4 In long-term follow-up, stroke risk increases due to age and accumulation of other risk factors.6 Physiologic factors that impact stroke prevention therapy also change over time and can have important implications for proper medication dosing and patient safety.5 Typically, periodic assessment should be performed once a year but might need to be performed more frequently in the context of changes in clinical status, such as reduction in renal function or development of additional risk factors.

6.3 Oral Anticoagulants

Vitamin K Antagonists Since the 1950s, warfarin was used as a first-line therapy until DOACs came into practice. A narrow therapeutic window based on international normalized ratios (INRs), frequent monitoring, more frequent drug interactions (mainly through CYP2C9), dietary restrictions, and low clinical safety profile affected the routine use of warfarin in practice. Because of affordability issues of DOACs for some patients with AF, warfarin is still an appropriate OAC due to its lower cost for patients who cannot afford DOACs. About 21% of patients with nonvalvular AF were still receiving warfarin, while the rest received DOACs in the first quarter of 2017.1 Warfarin remains the first-line therapy in

Table 9.  Some Best Known Published Clinical Scores With Potential Advantages

Year of Publication, Score Name Score Components Potential Advantages No. of Validation Studies19 Hyperlink to Online Score Calculator, if Available 2001 CHADS2 25 CHF, hypertension, age (≥65 y is 1 point, ≥75 y is 2 points), diabetes, stroke/TIA (2 points) CHADS2 was superior to existing risk classification schemes AFI scheme: C-statistic, 0.68 (0.65–0.71) SPAF-III scheme: C-statistic, 0.74 (0.71–0.76) CHADS2 score: C-statistic, 0.82 (0.80–0.84) 46 https://www.mdcalc.com/calc/40/ chads2-score-atrial-fibrillation- stroke-risk 2010 CHA2DS2-VASc2 CHF, hypertension, age ≥75 y, diabetes, stroke or TIA, vascular disease, age 65–74 y, female sex Most commonly used and studied, superior to CHADS2 score. C-statistic, 0.606 (0.513–0.699) for CHA2DS2-VASc score vs 0.561 (0.450–0.672) for CHADS2 score Improved compared with original CHADS2 score 82 https://www.mdcalc.com/ calc/801/cha2ds2-vasc-score- atrial-fibrillation-stroke-risk#next- steps 2013 ATRIA1 Age (65–74 y is 3 points, 75–84 y is 5 points, ≥85 y is 6 points), hypertension, diabetes, CHF, proteinuria, GFR <45 mL/ min/1.73 m2, sex Includes more age categories, renal function, and proteinuria More patients were classified as low or high risk but not as well tested in general. 11 https://www.mdcalc.com/ calc/1842/atria-stroke-risk-score 2017 GARFIELD-AF3 Web-based, uses routinely collected clinical data, and includes a total of 16 questions Web-based tool for predicting stroke and mortality, includes the effect of the different anticoagulants, bleeding risk and mortality to facilitate shared decision-making on the potential benefits/risks of anticoagulation 4 https://af.garfieldregistry.org/ garfield-af-risk-calculator 2016 MCHA2DS2-VASc26 Expanded lower threshold for age to 50 y (1 point for age 50–74 y) Validated in Asian cohort Can further identify Asian AF patients who may derive benefits from stroke prevention. In 1 study, MCHA2DS2-VASc was superior to CHA2DS2-VASc C-statistics = 0.708 (0.703–0.712) vs 0.689 (0.684–0.694) 1 ATRIA indicates Anticoagulation and Risk Factors in Atrial Fibrillation: anemia, renal disease, elderly (age ≥75 y), any previous bleeding, hypertension; CHADS2, congestive heart failure, hypertension, age >75 y, diabetes, stroke/transient ischemia attack/thromboembolism; CHA2DS2-VASc, indicates congestive heart failure, hypertension, age ≥75 y (doubled), diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism (doubled), vascular disease, age 65 to 74 y, sex category; CHF, congestive heart failure; GARFIELD-AF, Global Anticoagulant Registry in the Field-Atrial Fibrillation; GFR, glomerular filtration rate; SPAF-III, stroke prevention atrial fibrillation, and TIA, transient ischemic attack.

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