2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation

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 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 AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) 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.

Keywords: APHRS; atrial fibrillation; consensus guidelines; stroke prevention.

FIGURE 1

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

FIGURE 2

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

FIGURE 3

Temporal trends of incidence of ED visits from AF‐related complications and OAC prescription rate. The figure was redraw and modified from the paper by Lee et al AF, atrial fibrillation; ED, emergency department; GI, gastrointestinal; ICH, intracranial hemorrhage; NOAC, non‐vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant.

FIGURE 4

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

FIGURE 5

Risks of adverse outcomes according to use of integrated ABC pathway in Asians. ABC, Atrial fibrillation Better Care; CI, confidence interval; HR, hazard ratio. The figure was based on the data adapted from the paper by Yoon et al

FIGURE 6

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

FIGURE 7

Cumulative incidences of increment of CHA₂DS₂‐VASc score to ≥1 (males) or ≥2 (females). AF, atrial fibrillation. The figure was redraw, and data were adapted from the papers by Chang et al. and Chao et al,

FIGURE 8

Use of OACs and risk of bleeding among patients received integrated care approach and usual care. AF, atrial fibrillation; NOAC, non–vitamin K antagonist oral anticoagulant; OACs, oral anticoagulants. The figure was redraw and modified from the paper by Guo et al

FIGURE 9

Stroke and bleeding risk assessment in AF. AF, atrial fibrillation; BP, blood pressure; INR, international normalized ratio; NOAC, non–vitamin K antagonist oral anticoagulant; NSAIDs, nonsteroidal anti‐inflammatory drugs; OACs, oral anticoagulants; TTR, time in therapeutic range. The figure was redraw and modified from the paper by Chang et al

FIGURE 10

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

FIGURE 11

Considerations about the use of NOACs for Asian patients with AF with a CHA₂DS₂‐VASc score of 1 (males) or 2 (females). AF, atrial fibrillation; NOAC, non–vitamin K antagonist oral anticoagulant

FIGURE 12

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

FIGURE 13

Factors tipping the balance between ischemic and bleeding risk in patients with AF presenting with ACS and/or undergoing PCI. ACS, acute coronary syndrome; AF, atrial fibrillation; BMI, body mass index; BRS, bioresorbable scaffold; CKD, chronic kidney disease; CTO, chronic total ccclusion; 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. The figure was redraw and modified from the paper by Vitolo et al

FIGURE 14

Anticoagulation therapy after elective PCI or ACS in patients with AF. A = aspirin 75–100 mg QD; C = clopidogrel 75 mg QD; Tica = Ticagrelor 90 mg BID. AF, atrial fibrillation; ACS, acute coronary syndrome; 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. The figure was redraw and modified from the 2021 European Heart Rhythm Association Practical Guide on the use of NOACs in patients with AF by Steffel et al

FIGURE 15

A flowchart about the general recommendation for NOACs in the periprocedural period of catheter ablation. NOACs, non–vitamin K antagonist oral anticoagulants; TEE, transeshophageal echocardiography

FIGURE 16

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

FIGURE 17

Recommendations about the dosing of NOACs according to renal function. bid, twice daily; CCr, creatinine clearance; qd, once daily; ESRD, end‐stage renal disease; NOACs, non–vitamin K antagonist oral anticoagulants; RRT, renal replacement therapy

FIGURE 18

Use of OACs after acute ischemic stroke or transient ischemic attack. CT, computed tomography; MRI, magnetic resonance imaging; NOAC, non–vitamin K antagonist oral anticoagulant; TIA, transient ischaemic attack. The figure was redraw and modified from the 2021 European Heart Rhythm Association Practical Guide on the use of NOACs in patients with AF by Steffel et al

FIGURE 19

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