CHEST Releases Guideline for Antithrombotic Therapy in Atrial Fibrillation

A blood clot shown with a light micrograph of a section through an arterial thrombus
A blood clot shown with a light micrograph of a section through an arterial thrombus
Patients with atrial fibrillation who have ≥1 non-sex CHA2DS2VASc stroke risk factor should receive oral anticoagulation as antithrombotic therapy.

Oral anticoagulation is the ideal choice of antithrombotic therapy in patients with atrial fibrillation (AF) who have ≥1 nonsex CHA2DS2VASc stroke risk factor, according to an updated guideline published in CHEST.

An expert panel conducted a systematic literature review to identify relevant articles that were published since the last guideline was released in 2012. The panel revised or added recommendations as needed, with a total of 60 included in the summary. The quality of the evidence in the literature was assessed using the GRADE approach.

Several key recommendations include:

  • Patients with AF who do not have valvular heart disease, including paroxysmal AF, and are at low risk for stroke should not receive antithrombotic therapy.
  • Patients with ≥1 nonsex CHA2DS2VASc stroke risk factors should be considered for stroke prevention using oral anticoagulation.
  • Oral anticoagulation vs no therapy, aspirin or combination therapy with aspirin, or clopidogrel should be used in patients with only 1 CHA2DS2VASc stroke risk factor.
  • Oral anticoagulation vs no therapy, aspirin, or combination therapy with aspirin and clopidogrel should be used in patients at high risk for stroke (CHA2DS2VASc ≥2 in men or ≥3 in women).
  • Whenever oral anticoagulation is recommended, a non-vitamin K antagonist oral anticoagulant should be used rather than an adjusted-dose vitamin K antagonist. Time in therapeutic range in the latter should be >70%, according to the panel.

The expert panel also recommended that clinicians be mindful of modifiable bleeding risk factors in patients such as uncontrolled blood pressure, labile international normalized ratios, excessive alcohol intake, or concomitant use of aspirin or nonsteroidal anti-inflammatory drugs in patients taking oral anticoagulants. The HAS-BLED score should be used to assess patients’ risk for bleeding, and high-risk patients (CHA2DS2VASc ≥3) should be followed up more often.

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“Aside from stroke prevention (‘Avoid Stroke, use Anticoagulants’), AF management requires patient centered and symptom directed decisions on rate or rhythm control (‘Better symptom management’) as well as ‘Cardiovascular and other risk factor, and lifestyle management,’ ” the panel wrote. “This simple ABC approach (Atrial fibrillation Better Care approach) would simplify an integrated approach to AF management in a holistic manner.”


Lip GYH, Banerjee A, Boriani G, et al. Antithrombotic therapy for atrial fibrillation: CHEST guideline and expert panel report [published online August 22, 2018]. CHEST. doi:10.1016/j.chest.2018.07.040