Personalized anti-thrombotic management of patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1–a statement of the ESCWorking Group on Cardiovascular Pharmacotherapy and ESC Council on Stroke

This commentary refers to ‘2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS)’ by G. Hindricks et al., 2021;42:373--498. In the recently published 2020 ESC guidelines on atrial fibrillation (AF), the avoidance of ischaemic events mirrors a key measure in the integrated holistic ‘ABC’ pathway of patient care. Subsequently, their recommendations on treatment decisions on the anti-thrombotic management remained basically unchanged and a risk-factor-based approach is still suggested, via using the CHA2DS2-VASc score to identify individuals at risk for ischaemic events.1 Noteworthy, addressing oral anticoagulation in individuals presenting with a CHA2DS2-VASc score of 1 in men, or 2 in women, the treatment recommendations were not modified, stating that anti-thrombotic treatment may be individualized based on the net clinical benefit of oral anticoagulation (OAC) in this risk category. Considering the complexity of a personalized anti-thrombotic management in patients with a CHA2DS2-VASc score of 1, the simplicity of treatment recommendations mentioned in the present 2020 AF guidelines mirrors a major advantage in terms of educational aspects. It needs to be taken into account that especially individuals in this risk category are the most vulnerable when addressing the initiation of an antithrombotic regimen via balancing the individual thromboembolic against the bleeding risk. Facing the difficulty to assess a net clinical benefit of OAC at a patient level, a recently published current opinion statement of the ESC Working Group on Cardiovascular Pharmacotherapy and the ESC Council on Stroke summarized available evidence in this field to guide clinicians through these complex treatment decisions.2 The respective current opinion statement mentioned that the patients’ age (>65 years) and diabetes mellitus type II mirror the most prominent isolated risk factors for thrombo-embolic events when addressing characteristics used for the calculation of the CHA2DS2-VASc score. Additionally, the burden of atrial arrhythmia—atrial fibrillation (not atrial flutter) and permanence/persistence of the arrhythmia—needs to be taken into account. Furthermore obesity (body mass index ≥ 30) and impaired kidney function—proteinuria (>150 mg/24 h or equivalent) or estimated glomerular filtration rate of <45 mL/h—were outlined as clinical patient characteristics that proved to be associated with an increased thrombo-embolic risk. Imaging values, such as enlarged left atrial volume (≥73 mL) or diameter (≥4.7 cm) or left atrial appendage emptying velocity (<20 cm/s) seem reasonable and easily assessable additional marker for risk stratification. Considering the importance of a biomarker-based strategy, cardiac troponin (positive high sensitivity troponin T or I) and Nt-proBNP (>1400 ng/L) proved to provide additional prognostic information to enhance risk estimation. Of note, the patients’ preferences are crucial for decision-making for or against OAC in order to ensure adherence to the respective treatment approach. The ESC Working Group on Cardiovascular Pharmacotherapy and the ESC Council on Stroke conclude that the major therapeutic preference in patients with a CHA2DS2-VASc score of 1 should be based on a careful balance between doing no harm as well as on avoiding a stroke. Most importantly, their recently published current opinion statement provides an easily applicable decision tree for the initiation of OAC, that guide clinicians through the question whether to provide an anti-thrombotic therapy or not and subsequently offers the currently most possible therapeutic benefit in this highly vulnerable patient population (Figure 1). Decision tree for OAC in patients with atrial fibrillation and a CHA2DS2-VASc score of 1 in men, or 2 in women and values for individual risk stratification. Values that favour oral anticoagulation and allow individual thrombo-embolic risk stratification in AF patients with a CHA2DS2-VaSc of 1. eGFR, estimated glomerular filtration rate; LA, left atrium; LAA, left atrial appendage; Nt-proBNP, N-terminal pro-B-type natriuretic peptide; NOAC, non-vitamin K antagonist oral anticoagulants; OAC, oral anticoagulation; VKA, vitamin K antagonist. Decision tree for OAC in patients with atrial fibrillation and a CHA2DS2-VASc score of 1 in men, or 2 in women and values for individual risk stratification. Values that favour oral anticoagulation and allow individual thrombo-embolic risk stratification in AF patients with a CHA2DS2-VaSc of 1. eGFR, estimated glomerular filtration rate; LA, left atrium; LAA, left atrial appendage; Nt-proBNP, N-terminal pro-B-type natriuretic peptide; NOAC, non-vitamin K antagonist oral anticoagulants; OAC, oral anticoagulation; VKA, vitamin K antagonist. Sven Wassmann (Cardiology Pasing, Munich, Germany and University of the Saarland, Homburg/Saar, Germany); Anne Grete Semb (Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway); Petr Widimsky (Cardiocenter, Third Faculty of Medicine, Charles University, Prague, Czech Republic); Thomas Gremmel (Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria and Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria); Juan Carlos Kaski (Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK); Gianluigi Savarese (Department of Medicine, Cardiology Division, Karolinska Institute, Karolinska University Hospital Solna, Stockholm, Sweden); Giuseppe M.C. Rosano (IRCCS San Raffaele Roma, Italy); Claudio Borghi (Atherosclerosis Research Unit, Medical and Surgical Sciences Department, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy); Keld Kjeldsen (Department of Cardiology, Copenhagen University Hospital [Amager-Hvidovre], Copenhagen, Denmark and Department of Health Science and Technology, The Faculty of Medicine, Aalborg University, Aalborg, Denmark); Christian Torp-Pedersen (Department of Health Sciences and Technology, Aalborg University, Aalborg, Denmark and Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark); Thomas Andersen Schmidt (Emergency Department, Hospital of North Zealand, University of Copenhagen, Denmark); Basil S. Lewis (Lady Davis Carmel Medical Center, Haifa, Israel and Technion-Israel Institute of Technology, Ruth and Bruce Rappaport School of Medicine, Haifa, Israel); Heinz Drexel (VIVIT Research, Landeskrankenhaus Feldkirch, Austria and Private University of the Principality of Liechtenstein, Principality of Liechtenstein); Juan Tamargo (Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Madrid, Spain); Dan Atar (Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norway); Stefan Agewall (Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norway) Conflict of interest: P.S. grants and personal fees from Böhringer Ingelheim, grants from Bristol Myers Squibb and grants from Astra Zeneca outside the submitted work.