Treating Afib with antithrombotics: updated CHEST guideline

  • Chest

  • curated by Jenny Blair, MD
  • Clinical Essentials
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  • Among patients with Afib and at least 1 CHA2DS2VASc stroke risk factor besides female sex, oral anticoagulants (OAC) are preferred.

Why this matters

  • New options and research relating to Afib thromboprophylaxis have emerged since the 2012 (9th) edition.
  • Most patients with Afib die from cardiac causes rather than stroke, suggesting a need for holistic prevention approaches.


  • 60 recommendations by CHEST expert panel relating to stroke prophylaxis among subgroups of Afib patients.
  • Only 6 carried over from previous guideline.
  • Recommendations based on systematic review and meta-analyses.
  • Funding: American College of Chest Physicians.

Key details

  • Afib patients without valvular disease, with low stroke risk per CHA2DS2VASc: no antithrombotic therapy (strong recommendation [SR], moderate-quality evidence [MQE]).
  • Afib patients with ≥1 (men) or ≥2 (women) non-sex-related CHA2DS2VASc stroke risk factor(s): OAC preferred vs no therapy, aspirin, or aspirin/clopidogrel (SR/MQE).
  • Novel OAC preferred over vitamin K antagonist (VKA) (SR/MQE).
  • For all Afib patients:
    • Presence or absence of symptoms should not dictate need for anticoagulation based on stroke risk (ungraded consensus-based [UCB]);
    • Regardless of stroke risk, avoid using only aspirin or aspirin/clopidogrel for stroke prevention (SR/MQE).
  • For all Afib patients, at each visit:
    • Assess modifiable risk factors (SR/low-quality evidence);
    • If HAS-BLED score ≥3, follow-up frequently (SR/MQE).
  • For Afib patients with acute coronary syndrome or undergoing percutaneous intervention (PCI)/stenting, assess stroke risk with CHA2DS2VASc score (SR/MQE).
  • For Afib patients experiencing acute ischemic stroke:
    • Avoid heparinoids or VKA in first 48 hours (UCB);
    • Use long-term OAC for secondary prevention (SR/high quality evidence);
    • Consider beginning within 2 weeks (UCB).
  • For Afib patients who have refused OAC, revisit decision, educate (UCB).
  • Additional recommendations address cardioversion, elective PCI/stenting, dosing, proton-pump or P2Y12 inhibitors, choice of anticoagulants for survivors of stroke or gastrointestinal bleeding, left atrial appendage occlusion, carotid revascularization, pregnancy, lactation, chronic kidney disease, and cardiac surgery.