Antithrombotic Therapy for Atrial Fibrillation Gregory Y.H. Lip, MD, Amitava Banerjee, MD, DPhil, Giuseppe Boriani, MD, PhD, Chern en Chiang, MD, PhD, Ramiz Fargo, MD, FCCP, Ben Freedman, MD, PhD, Deirdre A. Lane, PhD, Christian T. Ruff, MD, MPH, Mintu Turakhia, MD, David Werring, PhD, Sheena Patel, MPH, Lisa Moores, MD, FCCP  CHEST  Volume 154, Issue 5, Pages 1121-1201 (November 2018) DOI: 10.1016/j.chest.2018.07.040 Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 1 The ABC pathway of integrated care management. ABC = Atrial fibrillation Better Care; NOAC = non-vitamin K antagonist oral anticoagulant drug; OAC = oral anticoagulant; VKA = vitamin K antagonist; TTR = time in therapeutic range. (Adapted from Lip.2) CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 2 Risk factors for bleeding with oral anticoagulation and antiplatelet therapy. aFor patients receiving VKA treatment. bDose adaptation based on patient’s age, body weight, and serum creatinine level. cWalking aids; appropriate footwear; home review to remove trip hazards; neurologic assessment where appropriate. dIncreased INR monitoring, dedicated OAC clinicals, self-monitoring/self-management, educational/behavioral interventions. APTs = antiplatelets; CKD-EPI = Chronic Kidney Disease Epidemiology Collaboration; CrCl = creatinine clearance; cTnT-hs = high-sensitivity troponin T; CYP = cytochrome P450; GDF-15 = growth differentiation factor-15; INR = international normalized ratio; NSAIDs = nonsteroidal antiinflammatory drugs; SBP = systolic blood pressure; vWF = von Willebrand factor. See Figure 1 legend for expansion of other abbreviations. CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 3 Practical application of bleeding risk assessment in patients with AF. AF = atrial fibrillation; EHR = electronic health record. See Figure 1 and 2 legends for expansion of other abbreviations. CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 4 Practical management algorithm. CHA2DS2-VASc = congestive heart failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female); HAS-BLED = hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile INR, elderly (0.65), drugs/alcohol concomitantly (1 point each); SAMe-TT2R2 score = awarding 1 point for each of the following: sex (female); age <60 y; medical history (≥3 comorbidities: hypertension, diabetes, coronary heart disease/myocardial infarction, peripheral artery disease, heart failure, prior stroke, lung disease, liver disease or renal failure); treatments (such as amiodarone); smoking status (double); and race (non-Caucasian, double). See Figure 1, 2, and 3 legends for expansion of other abbreviations. CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 5 Management of patients with active bleeding on oral anticoagulation (NOAC and VKA). FFP = fresh frozen plasma; PCC = prothrombin complex concentrate; PRBC = packed RBCs. See Figure 1 legend for expansion of other abbreviations. CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 6 A-C, Management of oral antiplatelet therapy in patients with (A) balanced thrombotic/bleeding risk, (B) low thrombotic/high bleeding risk, and (C) high thrombotic/low bleeding risk. See Figure 1 legend for expansion of abbreviations. (Adapted from Angiolillo et al.202) CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 7 Flowchart for clinical management and decision-making in patients with CIEDs-detected AHRE. AHRE = atrial high-rate episode; CIED = cardiac implanted electrical device. See Figure 1, 3, and 4 legends for expansion of other abbreviations. CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 8 Management of women with AF during pregnancy is shown. LMWH = low-molecular-weight heparin. See Figure 1 and 3 legends for expansion of other abbreviations. CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions

Figure 9 Suggested algorithm for the decision-making process in prescribing OAC therapy in patients with various degrees of renal function impairment. aThe 110-mg dose is not available in the United States. Unless the patient is elderly or has high bleeding risk or is taking p-glycoprotein inhibitors, where dabigatran 110 mg bid is preferred, except in the United States, where the 110-mg dose is not available. bUse 2.5 mg bid if 2 of 3 of the following criteria are present: age > 80 years, weight < 60 kg, or serum creatinine > 133 mmol/L. cIn the United States, caution is advised when CrCl is > 95 mL/min. ESRD = end-stage renal disease; RRT = renal replacement therapy. (Adapted from Lau et al.437) See Figure 1 and 2 legends for expansion of other abbreviations. CHEST 2018 154, 1121-1201DOI: (10.1016/j.chest.2018.07.040) Copyright © 2018 American College of Chest Physicians Terms and Conditions