2021 Focused Update Consensus Guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: Executive Summary

Abstract

The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in the Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The practice guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of the AF Better Care pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian AF patients with single one stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.

Fig. 1

Projected prevalence of AF in Taiwan and South Korea. Data used in the figure were adapted from Chao et al and Kim et al. AF, atrial fibrillation.

Fig. 2

Temporal trend of prescriptions of OACs and risks of clinical events in newly diagnosed AF patients. The figure was redrawn and data were adapted from Chao et al. AF, atrial fibrillation; OACs, oral anticoagulants.

Fig. 3

The ABC pathway of integrated care management. The figure was redrawn and modified from Lip et al. ABC, Atrial fibrillation Better Care; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; TTR, time in therapeutic range; VKA, vitamin K antagonist.

Fig. 4

Impacts of adherence to the ABC pathway on clinical outcomes in AF patients. The figure was redrawn and modified from Romiti et al. ABC, Atrial fibrillation Better Care; CI, confidence interval; OR, odds ratio.

Fig. 5

Cumulative incidences of increment of CHA ₂ DS ₂ -VASc score to ≥1 (males) or ≥2 (females). The figure was redrawn and data were adapted from Chang et al and Chao et al. AF, atrial fibrillation.

Fig. 6

Use of OACs and risk of bleeding among patients who received integrated care approach and usual care. The figure was redrawn and modified from Guo et al. AF, atrial fibrillation; BP, blood pressure; INR, international normalized ratio; NOAC, non-vitamin K antagonist oral anticoagulant; OACs, oral anticoagulants.

Fig. 7

Stroke and bleeding risk assessment in AF. The figure was redrawn and modified from Chang et al. AF, atrial fibrillation; NOAC, non-vitamin K antagonist oral anticoagulant; NSAIDs, nonsteroidal anti-inflammatory drugs; OACs, oral anticoagulants; TTR, time in therapeutic range.

Fig. 8

Three-step approach for the use of OACs for stroke prevention in AF. The flowchart was redrawn and modified from Lip et al. AF, atrial fibrillation; INR, international normalized ratio; NOAC, non-vitamin K antagonist oral anticoagulant; OACs, oral anticoagulants; VKA, vitamin K antagonist.

Fig. 9

Considerations about the use of NOACs for Asian AF patients with a CHA ₂ DS ₂ -VASc score of 1 (males) or 2 (females). AF, atrial fibrillation; NOAC, non-vitamin K antagonist oral anticoagulant.

Fig. 10

Increasing use of OACs (especially NOACs) and combination therapy with antiplatelet agents among AF patients undergoing percutaneous coronary intervention. The figure was redrawn and data were adapted from Kwon et al. AF, atrial fibrillation; DAPT, dual antiplatelet therapy; NOAC, non-vitamin K antagonist oral anticoagulant.

Fig. 11

Factors tipping the balance between ischemic and bleeding risk in AF patients presenting with ACS and/or undergoing PCI. The figure was redrawn and modified from Vitolo et al. ACS, acute coronary syndrome; AF, atrial fibrillation; BMI, body mass index; BRS, bioresorbable scaffold; CKD, chronic kidney disease; CTO, chronic total occlusion; DAT, dual antithrombotic therapy; DES, drug-eluting stent; ESRD, end-stage renal disease; LAD, left anterior descending artery; MI, myocardial infarction; NSAID, nonsteroidal anti-inflammatory drug; PCI, percutaneous coronary intervention; TAT, triple antithrombotic therapy.

Fig. 12

Anticoagulation therapy after elective PCI or ACS in AF patients. A, aspirin 75–100 mg QD; C, clopidogrel 75 mg QD; Tica, ticagrelor 90 mg BID. The figure was redrawn and modified from the 2021 European Heart Rhythm Association Practical Guide on the use of NOACs in patients with AF by Steffel et al. ACS, acute coronary syndrome; AF, atrial fibrillation; BID, twice daily; BMS, bare metal stent; DES, drug-eluting stent; LAD, left anterior descending artery; MI, myocardial infarction; NOAC, non-vitamin K antagonist oral anticoagulant; PCI, percutaneous coronary intervention; PPI, proton pump inhibitor; QD, once daily.

Fig. 13

A flow chart about the general recommendation for NOACs in the periprocedural period of catheter ablation. NOACs, non-vitamin K antagonist oral anticoagulants; TEE, transesophageal echocardiography.

Fig. 14

General principles of managements of bleeding for anticoagulated AF patients. AF, atrial fibrillation; FFP, fresh frozen plasma; NOACs, non-vitamin K antagonist oral anticoagulants; OACs, oral anticoagulants.

Fig. 15

The integration of lifestyle management in patients with AF. AF, atrial fibrillation.