Clinical Benefit of American College of Chest Physicians versus European Society of Cardiology Guidelines for Stroke Prophylaxis in Atrial Fibrillation

BACKGROUND

Guidelines for anticoagulant therapy in patients with atrial fibrillation (AF) conflict with each other. The American College of Chest Physicians (ACCP) guidelines suggest no anticoagulant therapy for patients with a CHADS₂ score of 0. The European Society of Cardiology (ESC) prefer anticoagulant therapy for patients with a CHA₂DS₂-VASc of 1, which includes 65–74-year-olds with a CHADS₂ score of 0. Resolving this conflicting advice is important, because these guidelines have potential to change anticoagulant therapy in 10 % of the AF population.

METHODS

Using the National Registry of Atrial Fibrillation (NRAF) II data set, we compared these guidelines using stroke equivalents. Based on structured review of 23,657 patient records, we identified 65–74-year-old patients with a CHADS₂ stroke score of 0 and no contraindication to warfarin. We used Medicare claims data to ascertain rates of ischemic stroke, intracranial hemorrhage, and other hemorrhage. We calculated net stroke equivalents for these (N = 478) patients using a weight of 1.5 for intracranial hemorrhages (ICH) and 1.0 for ischemic stroke. In a multivariate analysis, we used 14,466 records with documented atrial fibrillation and adjusted for CHADS₂ and HEMORR₂ HAGES score.

RESULTS

In 65–74-year-old patients with a CHADS₂ stroke score of 0, the stroke equivalents per 100 patient-years was 2.6 with warfarin and 2.9 without warfarin; the difference between these two strategies was not significant (0.3 stroke equivalents, 95 % CI −3.2 to 3.7). However, rates of hemorrhage per 100 patient-years were nearly tripled (hazard ratio 2.9; 95 % CI 1.5–5.4; p = 0.0011) with warfarin (21.1) versus without it (7.4). The most common site for major hemorrhage was gastrointestinal (ICD-9 code 578.9).

CONCLUSIONS

By expanding warfarin use to 65-–74-year-olds with a CHADS₂ score of 0, rates of hemorrhages would rise without a significant reduction in stroke equivalents.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3201-1) contains supplementary material, which is available to authorized users.KEY WORDS: atrial fibrillation, epidemiology, outcomes, stroke, thromboembolismAtrial fibrillation (AF) is the most common cardiac arrhythmia, and stroke prevention is a cornerstone of treatment in these patients. However, guidelines regarding anticoagulant therapy conflict with one another. The 2012 American College of Chest Physicians (ACCP) guidelines recommend the use of oral anticoagulant therapy in patients with AF who have a Congestive heart failure, Hypertension, Age > 75, Diabetes mellitus, and prior Stroke (CHADS₂) score of 1 or greater.¹ ACCP suggests no anticoagulant therapy for patients with a CHADS₂ score of 0.¹ However, the ACCP guidelines remark that there are other factors, such as age 65 to 74 years, female gender, vascular disease, and patient preferences, that may influence the choice of therapy for some patients.These guidelines differ from the 2010 European Society of Cardiology (ESC) (Table 2 The 2012 ESC AF Focused Update³ and the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS)⁴ recommend anticoagulant therapy if AF patients age 65–74 are female or have vascular disease (because their CHA₂DS₂-VASc score would be 2 or more). However, for other 65–74-year-old patients with a CHADS₂ score of 0 they state that either no antithrombotic therapy or treatment with an oral anticoagulant should (2012 ESC) or may (AHA/ACC/HRS) be considered because their CHA₂DS₂-VASc score would be 1.

Table 1

Atrial Fibrillation Guidelines for Use of Anticoagulant Therapy in 65–74-year-Olds

Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society

DESCRIPTION: This guideline is an official statement of the American College of Physicians (ACP), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), and European Respiratory Society (ERS). It represents an update of the 2007 ACP clinical practice guideline on diagnosis and management of stable chronic obstructive pulmonary disease (COPD) and is intended for clinicians who manage patients with COPD. This guideline addresses the value of history and physical examination for predicting airflow obstruction; the value of spirometry for screening or diagnosis of COPD; and COPD management strategies, specifically evaluation of various inhaled therapies (anticholinergics, long-acting β-agonists, and corticosteroids), pulmonary rehabilitation programs, and supplemental oxygen therapy. METHODS: This guideline is based on a targeted literature update from March 2007 to December 2009 to evaluate the evidence and update the 2007 ACP clinical practice guideline on diagnosis and management of stable COPD. RECOMMENDATION 1: ACP, ACCP, ATS, and ERS recommend that spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). RECOMMENDATION 2: For stable COPD patients with respiratory symptoms and FEV(1) between 60% and 80% predicted, ACP, ACCP, ATS, and ERS suggest that treatment with inhaled bronchodilators may be used (Grade: weak recommendation, low-quality evidence). RECOMMENDATION 3: For stable COPD patients with respiratory symptoms and FEV(1) <60% predicted, ACP, ACCP, ATS, and ERS recommend treatment with inhaled bronchodilators (Grade: strong recommendation, moderate-quality evidence). RECOMMENDATION 4: ACP, ACCP, ATS, and ERS recommend that clinicians prescribe monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled β-agonists for symptomatic patients with COPD and FEV(1) <60% predicted. (Grade: strong recommendation, moderate-quality evidence). Clinicians should base the choice of specific monotherapy on patient preference, cost, and adverse effect profile. RECOMMENDATION 5: ACP, ACCP, ATS, and ERS suggest that clinicians may administer combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled β-agonists, or inhaled corticosteroids) for symptomatic patients with stable COPD and FEV(1)<60% predicted (Grade: weak recommendation, moderate-quality evidence). RECOMMENDATION 6: ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an FEV(1) <50% predicted (Grade: strong recommendation, moderate-quality evidence). Clinicians may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV(1) >50% predicted. (Grade: weak recommendation, moderate-quality evidence). RECOMMENDATION 7: ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (Pao(2) ≤55 mm Hg or Spo(2) ≤88%) (Grade: strong recommendation, moderate-quality evidence).     

Representation of Women in Atrial Fibrillation Clinical Practice Guidelines

BackgroundAtrial fibrillation (AF) is the most common arrhythmia in men and women worldwide, and its prevalence is increasing. Management of AF is guided by evidence-based clinical practice guidelines which provide recommendations based on available evidence. The extent of sex-specific data in the AF literature used to provide guideline recommendations has not been investigated. Therefore, using the 2020 Canadian Cardiovascular Society (CCS) AF management guidelines as an example, the purpose of this study was to review female representation and the reporting of sex-disaggregated data in the studies referenced in AF guidelines.MethodsRandomised controlled trials (RCTs) and prospective and retrospective cohorts were screened to calculate the proportion of study participants who were female and to establish whether studies provided sex-disaggregated analyses. The participant-prevalence ratio (PPR), a quotient of the female participant rate and the prevalence of women in the AF population, was calculated for each study.ResultsA total of 885 studies included in the CCS guidelines were considered. Of those, 467 met the inclusion criteria. Overall, women represented 39.1% of the population over all of the studies and RCTs had the lowest proportions of women (33.8%, PPR 0.70). Of studies with sex-disaggregated analyses (n = 140; 29.9%), single-centre RCTs and retrospective cohorts had the lowest and highest rates of sex-specific analyses, respectively (11.5% and 32.5%).ConclusionsThe evidence used to derive guideline recommendations may be inadequate for sex-specific recommendations. Until enough data can support women-specific guidelines, increased inclusion of females in AF studies, may aid in the precision of recommendations.     

Prediction of Stroke Risk in Atrial Fibrillation,Prevention of Stroke in Atrial Fibrillation,and the Impact of Long-Term Monitoring for Detecting Atrial Fibrillation

Atrial fibrillation (AF) is a large public health problem that affects about 1% of the population in the United States. It confers an increased risk for stroke and thromboembolism, but the stroke risk is not equal in all patients. Further refinement in stratifying stroke risk in patients with AF will help in properly directing therapy for AF patients while minimizing adverse events. Warfarin is the first-line treatment for stroke reduction in patients with AF, but many new drugs are on the horizon that will significantly change practice. New and improved cardiac monitoring techniques and devices will help with detection of AF in those at risk for stroke and will assist in assessing which patients will most benefit from anticoagulation.