Antithrombotic Therapy for Atrial Fibrillation CHEST Guideline and Expert Panel Report
Antithrombotic Therapy for Atrial Fibrillation CHEST Guideline and Expert Panel Report
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DOI：
10.1016/j.chest.2018.07.040
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发表时间：
2018-11-01
期刊：
影响因子：
9.6
通讯作者：
Moores, Lisa
中科院分区：
文献类型：
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作者：
Lip, Gregory Y. H.;Banerjee, Amitava;Moores, Lisa
背景：不同类型的房颤患者发生卒中的风险是不同的，取决于各种卒中危险因素的存在。我们根据不同卒中风险水平的房颤患者的净临床益处和一些常见的临床情况，提供抗血栓治疗的建议。方法：通过系统的文献综述来确定最近一次正式检索抗血栓和溶栓治疗：美国胸科医师学会循证临床实践指南(第9版)发表的相关文章。证据的总体质量使用分级(分级建议、评估、发展和评估)方法进行评估。结果：对于没有瓣膜心脏病的房颤患者，包括那些卒中风险较低的阵发性房颤患者(例如，CHA(2)DS(2)-VASC[充血性心力衰竭、高血压、年龄和GT；=75(加倍)、糖尿病、中风(加倍)-血管疾病，年龄65-74岁和性别类别(女性)]，男性0分或女性1分)，我们建议不进行抗血栓治疗。下一步是考虑对具有一个或多个非性别CHA(2)DS(2)-VASC卒中危险因素的患者进行卒中预防(即口服抗凝治疗)。对于有单一非性别CHA(2)DS(2)-VASC卒中危险因素的患者，我们建议口服抗凝而不是不治疗，阿司匹林或阿司匹林和氯吡格雷的联合治疗；对于中风的高危患者(例如，CHA(2)DS(2)-VASC>；=2男性或3女性)，我们建议口服抗凝而不是不治疗，阿司匹林，或阿司匹林和氯吡格雷的联合治疗。如果我们建议或建议口服抗凝，我们建议使用非维生素K拮抗剂口服抗凝药物，而不是调整剂量的维生素K拮抗剂治疗。对于后者，重要的是要以良好的抗凝控制为目标，治疗范围为>；70%。注意可改变的出血危险因素(例如，失控的血压，不稳定的国际正常化比率，同时使用阿司匹林或抗凝患者的非类固醇抗炎药物，酒精过量)，应在每个患者接触时注意，并已出血(高血压，肾/肝功能异常[各1分]，中风，出血史或倾向，不稳定的国际正常化比率，老年人(0.65)，药物/酒精伴随[各1分])评分，用于评估高危患者出血的风险(>；结论：对于>；=1非性别CHA(2)DS(2)-VASc卒中危险因素(S)的房颤患者，口服抗凝是抗血栓治疗的最佳选择。
BACKGROUND: The risk of stroke is heterogeneous across different groups of patients with atrial fibrillation (AF), being dependent on the presence of various stroke risk factors. 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: Systematic literature reviews were conducted to identify relevant articles published from the last formal search perfomed for the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition). The overall quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted, voted on, and revised until consensus was reached.RESULTS: For patients with AF without valvular heart disease, including those with paroxysmal AF, who are at low risk of stroke (eg, CHA(2)DS(2)-VASc [congestive heart failure, hypertension, age >= 75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)] score of 0 in males or 1 in females), we suggest no antithrombotic therapy. The next step is to consider stroke prevention (ie, oral anticoagulation therapy) for patients with 1 or more non-sex CHA(2)DS(2)-VASc stroke risk factors. For patients with a single non-sex CHA(2)DS(2)-VASc stroke risk factor, we suggest oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel; and for those at high risk of stroke (eg, CHA(2)DS(2)-VASc >= 2 inmales or >= 3 in females), 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 using a non-vitamin K antagonist oral anticoagulant drug rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range > 70%. Attention to modifiable bleeding risk factors (eg, uncontrolled BP, labile international normalized ratios, concomitant use of aspirin or nonsteroidal antiinflammatory drugs in an anticoagulated patient, alcohol excess) should be made at each patient contact, and HAS-BLED (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile international normalized ratio, elderly (0.65), drugs/alcohol concomitantly [1 point each]) score used to assess the risk of bleeding where high risk patients (>= 3) should be reviewed and followed up more frequently.CONCLUSIONS: Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with >= 1 non-sex CHA(2)DS(2)-VASc stroke risk factor(s).