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    • As Table shows all guidelines

    2019-05-29

    As Table 2 shows, all guidelines recommend OACs for patients with a CHADS2 score of ≥2, whereas recommendations for low-risk patients with a CHADS2 score of 0/1 differ slightly across guidelines. Evidence indicating that novel OACs decrease the risk of ICH by half as compared with warfarin has affected the recommendations of guideline documents. The ESC 2010 guidelines are the first among the guidelines reviewed to introduce the CHA2DS2-VASc score, and recommend physicians to classify low-risk patients with a CHADS2 score of 0/1 into 3 subgroups. In the CHA2DS2-VASc score, the major risk factors (2 points) are prior stroke or transient ischemic attack (TIA), and older age (≥75 years), and the clinically relevant nonmajor risk factors (1 point) are dna repair pathways failure, hypertension, diabetes mellitus, female sex, age 65−74 years, and vascular disease. The ESC 2010 guidelines recommend OAC for patients with a CHA2DS2-VASc score of ≥2, OAC or ASA (OAC is more preferable) for patients with a score of 1, and no treatment or ASA for those with a score of 0 (no treatment is more preferable). Dabigatran is the OAC of choice. The JCS 2008 guidelines adopted a similar concept, and describe that physicians may consider warfarin and dabigatran for patients with risk factors other than those used in the CHADS2 score, such as age 65−74 years, female sex, and having coronary artery disease as those with a CHADS2 score of 1. The Australian 2011 guidelines and the ACCP 2012 guidelines use the CHADS2 score but differ slightly in treatment for patients with a CHADS2 score of 0 and 1. On the other hand, the CCS 2012 guidelines use the concept of the CHA2DS2-VASc score but weigh factors in a way different from those in the ESC 2010 guidelines. The CCS 2012 guidelines weighed factors that were defined as clinically relevant nonmajor factors in the ESC 2010 guidelines differently, and recommend the following treatment for patients with a CHADS2 score of 0: OAC for those 65–74 years of age or female patients with vascular disease; ASA for female patients or those with vascular disease; and no treatment for male patients <65 years old. The CCS 2012 guidelines recommend OAC for patients with a CHADS2 score of 1. In all cases, ASA is recommended as an alternative to warfarin. As mentioned above, there is a slight difference among guidelines in handling female sex as a risk factor in the assessment of low-risk patients by using the CHA2DS2-VASc score. As Table 3 shows, the ESC 2012 focused update guidelines [5] recommend the use of the CHA2DS2-VASc score in the assessment of all patients, including high-risk patients. However, the ESC 2012 focused update guidelines recommend “no antithrombotic therapy” for patients “<65 years and lone AF (including females)” since the risk of stroke is considered low in this patient population [16]. In the CHA2DS2-VASc score, “female sex” is a clinically relevant nonmajor risk factor with a CHA2DS2-VASc score of “1,” although female patients may be considered at low risk if they are “under 65 years of age.” Female patients ≥65 years of age should have a CHA2DS2-VASc score of 2, and they are recommended to receive OAC. The present APHRS statement uses similar criteria for female patients. In the APHRS survey, we assessed the use of the CHA2DS2-VASc score in the 9 member countries [10]. A questionnaire survey conducted in June to August 2011 revealed that 47% and 45% of physicians are using the CHADS2 and CHA2DS2-VASc scores, respectively. The CHA2DS2-VASc score is used by more than half of the respondents in New Zealand (86%), India (59%), Singapore (57%), and Australia (54%), whereas the CHADS2 score is widely used in Japan (70%), Hong Kong (61%), and Taiwan (57%). Since evidence has shown the superiority of the CHA2DS2-VASc score, and its use is recommended in many countries, the APHRS decided to recommend the use of this score in the guideline. Both cardiologists and general practitioners in the Asia-Pacific region should be encouraged to use the CHA2DS2-VASc score as a basic risk assessment method for selecting better anticoagulation therapy.