Atrial fibrillation: stroke prevention and anticoagulation

ACC/AHA/ACCP/HRS2023

Anticoagulate by annual thromboembolic risk, not score alone. Class 1 if risk ≥2%/yr (CHA2DS2-VASc ≥2 men, ≥3 women). Class 2a if 1 to 2%/yr (score 1 men, 2 women). DOACs preferred over warfarin except with a mechanical heart valve or moderate to severe rheumatic mitral stenosis (use warfarin). Aspirin alone or with clopidogrel as an OAC alternative is not recommended (Class 3: Harm).

ACC/AHA/ACCP/HRS2023

Percutaneous LAA occlusion (eg, Watchman) is reasonable (Class 2a) with CHA2DS2-VASc ≥2 and a contraindication to long-term OAC from a nonreversible cause, upgraded from 2b in 2019. May be a reasonable alternative (Class 2b) at moderate to high stroke risk plus high bleeding risk on OAC. Device-detected AHRE ≥24 h with CHA2DS2-VASc ≥2: reasonable to start OAC (2a); 5 min to 24 h with score ≥3: may be reasonable (2b); under 5 min: no OAC.

USPSTF2022Grade I

Screening for atrial fibrillation in asymptomatic adults 50 and older: evidence insufficient to assess the balance of benefits and harms (I statement). Applies to adults without a diagnosis or symptoms of AF and without prior TIA or stroke. Consistent with the 2018 recommendation on ECG screening.

ACC/AHA/ACCP/HRS2023Grade Class 1

Risk factor modification is part of AF treatment: weight loss with an ideal target of at least 10% if BMI >27 (LOE B-R); moderate-to-vigorous exercise training toward 210 minutes per week (B-R); minimize or eliminate alcohol when rhythm control is sought (B-R); strongly advise smoking cessation with guideline-directed cessation therapy (B-NR). These reduce AF symptoms, burden, recurrence, and progression.

ACC/AHA/ACCP/HRS2023Grade Class 1 / 2a

Decide rate versus rhythm control by shared decision-making (Class 1). Without HF, a resting heart rate generally under 100 to 110 bpm, guided by symptoms, is a reasonable rate target (2a). Rhythm control can be useful within 1 year of diagnosis (2a) and should be tried when LV function is reduced with persistent AF (Class 1). Catheter ablation is first-line for selected younger patients with symptomatic paroxysmal AF (Class 1, LOE A).