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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e34

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

Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation]; ARISTOTLE; and ENGAGE AF-TIMI 48 [Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation – Thrombolysis in Myocardial Infarction 48]) included patients with this level of risk.1–4 Patients at intermediate risk (1%-2%/y) can also benefit from anticoagulation, and the RE-LY1 and ARISTOTLE3 trials included this population. Stroke risk scores applied to cohorts give different stroke rates, and therefore any score should be viewed as only an estimate of true risk; in addition some scores used stroke, while others used thromboembolic events. Nonetheless, it is practical to use a validated risk score, such as CHA2DS2-VASc, ATRIA, or GARFIELD-AF. Future research may yield improved risk scores that refine how to incorporate risk modifiers, such as female sex12 and other parameters such as AF burden. Anticoagulation has also been shown to be superior to antiplatelet therapy to reduce stroke risk.8,9 Recommendations for antithrombotic selection in valvular heart disease (VHD) are provided in Section 6.8.5 (“AF in VHD”) and for AFL in Section 6.8.6 (Figure 10).

Recommendation-Specific Supportive Text 1.	 Randomized trials published in the 1990s estab-

lished the superiority of anticoagulation, at that time limited to warfarin, to reduce stroke.11 Since that time, management has advanced considerably, and the randomized trials that compared DOACs with warfarin1–4 are more relevant to current antithrombotic management. In these trials1–4 and metanalyses,5–7 DOACs were favored for lower risk of stroke, systemic embolism, and ICH.1–7 These trials reported the CHADS2 score. The recently studied ATRIA and Swedish cohorts13,14 reported lower stroke rates, by CHADS2 score, compared with that previously reported.15 A CHADS2 score of 1 gave a stroke rate of 1.20 in ATRIA14 and 2.4 in a Swedish cohort.13 A CHADS2 score of 2

Table 12.  Thromboembolic Event Rates by Point Score for ATRIA, CHADS2, and CHA2DS2-VASc Risk Scores* ATRIA CHADS2† CHA2DS2-VASc‡

Points Events Person-Years Rate per 100 Person-Years Events Person-Years Rate per 100 Person-Years Events Person-Years Rate per 100 Person-Years 0 2 2652 0.08 22 6126 0.36 1 2493 0.04 1 12 2819 0.43 121 10 084 1.20 21 3806 0.55 2 14 1419 0.99 253 9757 2.59 46 5560 0.83 3 13 1780 0.73 178 4782 3.72 121 7305 1.66 4 19 2960 0.64 81 1309 6.19 193 6898 2.80 5 36 3614 0.99 19 450 4.23 175 4057 4.31 6 83 4346 1.91 11 101 10.84 85 1783 4.77 7 119 4768 2.50 — — — 24 498 4.82 8 151 3913 3.86 — — — 14 179 7.82 9 104 2400 4.33 — — — 5 30 16.62 10 75 1181 6.35 — — — — — — 11 31 501 6.18 — — — — — — 12 20 183 10.95 — — — — — — 13 4 53 7.52 — — — — — — 14 2 12 16.36 — — — — — — 15 0 7 0 — — — — — — All 685 32 609 2.10 — — — — — — Reproduced with permission from Singer et al.1 Copyright 2013 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley-Blackwell. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

*Black lines identify thresholds for low-, moderate-, and high-risk categories for the 3 stroke risk point scores using published cut points.8,9 †The CHADS2 score assigns points as follows: 1 point each for the presence of congestive heart failure, hypertension, age ≥75 y, and diabetes mellitus and 2 points for history of stroke/transient ischemic attack. ‡The CHA2DS2-VASc score assigns points as follows: 1 point each for congestive heart failure/left ventricular dysfunction, hypertension, diabetes mellitus, vascular disease, age 65 to 74 y, and female sex, and 2 points each for age ≥75 y and stroke/transient ischemic attack/thromboembolism. 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; and 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.

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