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Review
. 2022 Aug 23;2(5):519-537.
doi: 10.1016/j.jacasi.2022.06.004. eCollection 2022 Oct.

Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 2)

Chern-En Chiang  1   2   3 , Tze-Fan Chao  2   4 , Eue-Keun Choi  5 , Toon Wei Lim  6 , Rungroj Krittayaphong  7 , Mingfang Li  8 , Minglong Chen  8 , Yutao Guo  9   10 , Ken Okumura  11 , Gregory Y H Lip  5   7   8   10   12
Affiliations
Review

Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 2)

Chern-En Chiang et al. JACC Asia. .

Abstract

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk for stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonistdirect oral anticoagulant agent (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions for which NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the past decade, and a more sophisticated strategy for patients with AF is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. The aim of this statement is to provide possible treatment options in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is part 2 of the statement.

Keywords: AF, atrial fibrillation; Asia; CKD, chronic kidney disease; CrCl, creatinine clearance; ESRD, end-stage renal disease; LAA, left atrial appendage; NOAC; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; VKA; VKA, vitamin K antagonist; atrial fibrillation; eGFR, estimated glomerular filtration rate; stroke.

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Conflict of interest statement

This work was supported in part by grants from the Ministry of Health and Welfare (MOHW111-TDU-B-211-134001) and intramural grants from the Taipei Veterans General Hospital (V111C-194). Dr Chiang has received honoraria from AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Merck Sharpe & Dohme, Novartis, Pfizer, and Sanofi. Dr Chao has received honoraria for lectures from Boehringer Ingelheim, Bayer, Pfizer, and Daiichi Sankyo. Dr Choi has received research grants or speaker fees from Bayer, Bristol Myers Squibb/Pfizer, Biosense Webster, Daiichi Sankyo, and Medtronic. Dr Krittayaphong has received honoraria from Bayer, Boehringer Ingelheim, Daiichi Sankyo, and Pfizer. Dr Li has received honoraria from Bayer and Boehringer Ingelheim. Dr Chen has received honoraria from Biosense Webster, St. Jude Medical, Medtronic, Bayer, and Boehringer Ingelheim. Dr Okumura has received honoraria from Daiichi Sankyo, Boehringer Ingelheim, Bristol Myers Squibb, Medtronic, Japan Lifeline, and Johnson & Johnson. Dr Lip is a consultant and speaker for Bristol Myers Squibb/Pfizer, Boehringer Ingelheim, and Daiichi Sankyo (no fees are received personally). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Flowchart of Management of Patients With Chronic Liver Disease∗ The Child-Pugh scoring system is used to guide the management of patients with chronic liver disease. ∗Rivaroxaban should not be used in patients with Child-Pugh B. INR = international normalized ratio; NOAC = non-vitamin K antagonist oral anticoagulant; PT = prothrombin time.
Figure 2
Figure 2
Simple Standardized Periprocedural Strategy for NOAC Use The interruption and resumption strategy for DOACs is based on the pharmacokinetic properties of NOACs, procedure-associated bleeding risk, and creatinine clearance (CrCl) levels. Refer to Table 8 to determine levels of periprocedural bleeding risk. CrCl = creatinine clearance; NOAC = non-vitamin K antagonist oral anticoagulant.
Figure 3
Figure 3
Management Strategy for Bleeding Events While Receiving NOAC Treatment When dealing with bleeding events, patients’ histories should be thoroughly checked, including types and doses of NOACs and other modifiable risk factors for bleeding, such as suboptimally treated hypertension, excess alcohol intake, concomitant antiplatelet therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, and others. Furthermore, regular interdisciplinary review and shared decision making are needed. ∗Defined by International Society on Thrombosis and Hemostasis (ISTH). aPCC = activated prothrombin complex concentrate; FXa = factor Xa; LAAO = left atrial appendage occlusion; NOAC = non-vitamin K antagonist oral anticoagulant; NSAID = non-steroidal anti-inflammatory drug; PCC = prothrombin complex concentrate.
Central Illustration
Central Illustration
Choice of Anticoagulant Agents According to Patient Characteristics Most of the recommendations were based on randomized controlled trials or their subgroup analyses and international guidelines. A few of them were based on data from real-world evidence (RWE) or indirect evidence. Modified with permission from Lip et al. ∗Type 2 valvular heart diseases were defined previously by a European consensus, including all valvular heart diseases but excluding mechanical valves and moderate to severe mitral stenosis. A = apixaban; AF = atrial fibrillation; CKD = chronic kidney disease; CrCl = creatinine clearance; D = dabigatran; E = edoxaban; NOAC = non-vitamin K antagonist oral anticoagulant; OAC = oral anticoagulant agent; R = rivaroxaban; RCT = randomized controlled trial; Ref = reference; TIA = transient ischemic attack; VKA = vitamin K antagonist.
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