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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e33

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

patients with AF and moderate-severe rheumatic mitral stenosis or mechanical heart valves. Clinical studies show that the target INR is between 2 and 3, and risk of bleeding becomes mostly apparent when INR exceeds 4. OAC use in special populations will be discussed in separate sections. Direct oral anticoagulants DOACs were developed to address the disadvantages of warfarin and are currently recommended as the first-line therapy over warfarin in patients with AF (except moderate to severe mitral stenosis or mechanical heart valve recipients) in this guideline. All 4 pivotal clinical trials comparing individual DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) with warfarin showed superiority or noninferiority to warfarin for the prevention of stroke or systemic embolism in patients with AF except for moderate to severe mitral stenosis or mechanical heart valve.2–5 They also showed significantly lower risks of major bleeding in the apixaban, dabigatran 110 mg twice daily group, and edoxaban 30 mg or 60 mg daily dose groups compared with the warfarin group or nonsignificant differences in major bleeding between dabigatran 150 mg twice daily group or the rivaroxaban group and warfarin. All DOAC groups showed significantly lower risks of intracranial hemorrhage (ICH) compared with warfarin. Gastrointestinal bleeding risks were significantly higher in the dabigatran 150 mg twice daily, edoxaban 60 mg once daily, and rivaroxaban groups compared with the warfarin group. However, the apixaban group did not significantly increase the risk of gastrointestinal bleeding compared with the warfarin group.

6.3.1 Antithrombotic Therapy

Recommendations for Antithrombotic Therapy Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 A 1 For patients with AF and an estimated annual

thromboembolic risk of ≥2% per year (eg, CHA2DS2-VASc score of ≥2 in men and ≥3 in women), anticoagulation is recommended to prevent stroke and systemic thromboembolism.1–7

1 A 2 In patients with AF who do not have a history of

moderate to severe rheumatic mitral stenosis or a mechanical heart valve, and who are candidates for anticoagulation, DOACs are recommended over warfarin to reduce the risk of mortality, stroke, systemic embolism, and ICH.1–7

2a A 3 For patients with AF and an estimated annual

thromboembolic risk of ≥1% but <2% per year (equivalent to CHA2DS2-VASc score of 1 in men and 2 in women), anticoagulation is reasonable to prevent stroke and systemic thromboembolism.1,3

3: Harm B-R 4 In patients with AF who are candidates for antico-

agulation and without an indication for antiplatelet therapy, aspirin either alone or in combination with clopidogrel as an alternative to anticoagulation is not recommended to reduce stroke risk.8,9

3: No Benefit B-NR 5.	 In patients with AF without risk factors for stroke,

aspirin monotherapy for prevention of thromboembolic events is of no benefit.10,11

Synopsis A high risk for stroke or systemic embolism is about 2% per year, and all the DOAC trials (Re-LY [Randomized Evaluation of Long-Term Anticoagulation Therapy]; ROCKET AF [Rivaroxaban Once Daily Oral Direct

Table 10.  Risk Factor Definitions for CHA2DS2-VASc Score as in the Original Article2 C Heart Failure The presence of signs and symptoms of either right (elevated central venous pressure, hepatomegaly, dependent edema) or left ventricular failure (exertional dyspnea, cough, fatigue, orthopnea, paroxysmal nocturnal dyspnea, cardiac enlargement, rales, gallop rhythm, pulmonary venous congestion) or both, confirmed by noninvasive or invasive measurements demonstrating objective evidence of cardiac dysfunction H Hypertension A resting blood pressure >140 mm Hg systolic and/or >90 mm Hg diastolic on at least 2 occasions or current antihypertensive pharmacological treatment A2 Age, additional risk/ point Age ≥75 y D Diabetes Fasting plasma glucose level ≥7.0 mmol/L (126 mg/dL) or treatment with hypoglycemic agent and/or insulin S2 Thromboembolism Either an ischemic stroke, transient ischemic attack, peripheral embolism, or pulmonary embolism V Vascular Disease Coronary artery disease (prior myocardial infarction, angina pectoris, percutaneous coronary intervention, or coronary artery bypass surgery) or peripheral vascular disease (the presence of any of the following: intermittent claudication, previous surgery or percutaneous intervention on the abdominal aorta or the lower extremity vessels, abdominal or thoracic vascular surgery, arterial and venous thrombosis) A Age standard risk/ weight Age 65–74 y Sc Sex Category Female sex Modified with permission from Lip et al.2 Copyright 2010, with permission from Elsevier.

Table 11.  Additional Risk Factors That Increase Risk of Stroke Not Included in CHA2DS2-VASc Higher AF burden/Long duration Persistent/permanent AF versus paroxysmal Obesity (BMI, ≥30 kg/m2) HCM Poorly controlled hypertension eGFR (<45 mL/h) Proteinuria (>150 mg/24 h or equivalent) Enlarged LA volume (≥73 mL) or diameter (≥4.7 cm) AF indicates atrial fibrillation; BMI, body mass index; eGFR, estimated glomerular filtration rate; HCM, hypertrophic cardiomyopathy; and LA, left atrium.

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