Figure 1
Flow diagram of inclusion/exclusion processes for the guidelines.
Table 1
Characteristics of 16 Guidelines on Antithrombotic Therapy in post-PCI Patients with AF.
| GUIDELINES IDENTIFIER, YEAR | ORGANIZATION(S) | REGION | TARGET POPULATION | AGREE SCORE, % | CONFLICTS OF INTEREST | PROPORTION OF PANE MEMBERS WITH REPORTED INDUSTRY RELATIONSHIP | GUIDELINE STATUS |
|---|---|---|---|---|---|---|---|
| AHA/ACC, 2019 | American Heart Association/American College of Cardiology | United Stated | AF | 77 | *SCI, *SCIR, DIR, DSFS, DTCO, DEMC, DADI | 7/15 | Strongly recommended |
| AHA/ACC, 2014 | American Heart Association/American College of Cardiology | United Stated | NSTE-ACS | 78 | *SCI, *SCIR, DIR, DSFS, DTCO, DEMC, DADI | 7/17 | Strongly recommended |
| ACCF/AHA, 2013 | American Heart Association/American College of Cardiology Foundation | United Stated | STE-ACS | 76 | *SCI, *SCIR, DIR, DSFS, DTCO, DEMC, DADI | 12/23 | Strongly recommended |
| Chest, 2018 | American College of Chest | American | AF | 78 | *SCI, *SCIR, DIR, DSFS, DTCO, DEMC, DADI | 8/12 | Strongly recommended |
| CCS, 2018 | Canadian Cardiovascular Society | Canada | CAD | 76 | *SCI, *SCIR, DSFS, DTCO, DADI | 13/22 | Strongly recommended |
| CCS, 2018 | Canadian Cardiovascular Society | Canada | AF | 74 | *SCI, *SCIR, DSFS, DTCO, DADI | 22/25 | Strongly recommended |
| ESC, 2020 | European Society of Cardiology | Europe | AF | 80 | *SCI, *SCIR, DSFS, DTCO, DEMC, DADI | 22/25 | Strongly recommended |
| ESC, 2020 | European Society of Cardiology | Europe | NSTE-ACS | 78 | *SCI, *SCIR, DSFS, DTCO, DEMC, DADI | 24/26 | Strongly recommended |
| ESC, 2019 | European Society of Cardiology | Europe | CCS | 74 | *SCI, *SCIR, DSFS, DTCO, DEMC, DADI | 22/25 | Strongly recommended |
| ESC, 2017 | European Society of Cardiology | Europe | CAD | 75 | *SCI, *SCIR, DSFS, DTCO, DEMC, DADI | 13/18 | Strongly recommended |
| NICE, 2013 | National Institute for Health and Care Excellence | United Kingdom | STE-ACS | 88 | *SCI, DSFS, DTCO, DEMC, DADI | 8/15 | Strongly recommended |
| NHFA/CSANZ,2016 | National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand | Australia and New Zealand | ACS | 77 | *SCI, DSFS, DTCO, DEMC, DAD | 29/29 | Strongly recommended |
| NHFA/CSANZ,2018 | National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand | Australia and New Zealand | AF | 73 | *SCI, DSFS, DTCO, DEMC, DAD | 16/18 | Strongly recommended |
| JCS, 2013 | Japanese Circulation Society | Japan | AF | 60 | - | 11/11 | Recommended |
| TSC, 2016 | Taiwan Society of Cardiology | Taiwan | AF | 55 | DIR, DSFS | 3/27 | Not recommended |
| TSC, 2018 | Taiwan Society of Cardiology | Taiwan | NSTEMI | 63 | DIR, DSFS | - | Recommended |
[i] * Relationship with industry reported by at least 1 person. SCI = statement about conflicts of interest of panel members present; SCIR = statement about conflicts of interest of external peer reviews present; DIR = disclosure of the identities of peer reviews; DSFS = disclosure of the specific sources of funding for all stages of guideline development; DTCO = disclosure the types of COI (financial and nonfinancial) that are relevant to the guidelines; DEMC = disclosure of the evaluation and management of the COI; DADI = disclosure of how to access the declarations of interests; CAD = coronary artery disease; STE-ACS = ST-Elevation Acute Coronary Syndromes; NSTE-ACS = Non-ST-Elevation Acute Coronary Syndromes; SCAD = Stable Coronary Artery Disease; ACS = Acute Coronary Syndromes; AF = Atrial Fibrillation.
Table 2
Recommendations in Guidelines on Antithrombotic Therapy after PCI in Atrial Fibrillation.
| GUIDELINE | RISK EVALUATION | ACS | ELECTIVE PCI/CCS | MONOTHERAPY | ||
|---|---|---|---|---|---|---|
| TRIPLE THERAPY | DUAL THERAPY | TRIPLE THERAPY | DUAL THERAPY | |||
| AHA2019 AF | CHA2DS2-VASc≥2 | O+A+P for 4–6w(b) | P+V/N has lower risk of bleeding | / | / | / |
| AHA2014 NSTEMI | / | V+A+P should be minimized to the extent() | / | / | / | / |
| AHA2013 STEMI | CHA2DS2-VASc≥2 | V+A+P should be minimized to the extent() | / | / | / | / |
| CHEST2018 AF | HAS-BLED (0–2) | O+A+P for 6 mo. (weak) | P+O up to 12 mo. | O+A+P for 1 mo. (weak) | P+O up to 12 mo. | O |
| HAS-BLED ≥ 3 | O+A+P for 1–3 mo. (weak) | P+O up to 12 mo. | O+A+P for 1 mo. (weak) | P+O up to 12 mo. | O | |
| HAS-BLED > CHA2DS2-VASc | / | P+O for 6–9 mo. (weak) | / | P+O for 6 mo. (weak) | O | |
| CCS2018 Antiplatelet | Age < 65 and CHADS2 = 0 | / | A+P for 12 mo. (Strong) | / | A+P for 6–12 mo. (Strong) | A+/-P |
| Age ≥ 65 or CHADS2 ≥ 1 | O+A+P for 6 mo. (weak) | P+O up to 12 mo. | / | P+O for1–12 mo. a P+O for3–12 mo. b | O | |
| CCS2018 AF | Age ≥ 65 or CHADS2 ≥ 1 | O+A+P for 6 mo. (strong) | P+O up to 12 mo. | / | P+O for1–12 mo. a P+O for3–12 mo. b | O |
| ESC, 2020 AF | High ischaemic risk | 1w<O+A+P <1 mo. (a) | P+O up to 12 mo. () | O+A+P <1 mo. (a) | P+O up to 12 mo. | O |
| Bleeding risk outweighs | O+A+P≤1 w. () | P+O up to 12 mo. () | O+A+P≤1 w. () | P+O up to 6 mo. | O | |
| ESC2020 NSTEMI | CHA2DS2-vasc≥1 | O+A+P≤1 w. () | P+O up to 12 mo. | / | / | O |
| High ischaemic risk | 1w<O+A+P <1 mo. (a) | P+O up to 12 mo. | / | / | ||
| High bleeding risk | O+A+P≤1 w. | P+O up to 6 mo. | / | / | O after 6 mo. | |
| ESC2019 CCS | stent thrombosis low | / | / | O+A+P≤1 w. (a) | / | O |
| high ischaemic risk | / | / | 1mo.<O+A+P <6 mo. (a) | / | O | |
| ESC2017 DAPT | high ischaemic risk | O+A+P for 6 mo.(a) | / | / | / | O |
| High bleeding risk | / | P+O up to 12 mo. (a) | / | / | O | |
| NICE2013 MI | / | P+V up to 12 mo. | / | / | / | O |
| NFHA2016ACS | HAS-BLED <3 | O+A+P for 3–6 mo. | A/P+O up to 12 mo. | / | / | O |
| HAS-BLED ≥ 3 | O+A+P for 1 mo. | A/P+O up to 12 mo. | / | / | O | |
| CHA2DS2-VASc = 1 | / | A+P up to 12 mo. | / | / | O | |
| NFHA2018 AF | high ischaemic risk | O+A+P for 1–6 mo. | A/P+O up to 12 mo. | O+A+P for 1 mo. | A/P+O until 12 mo. | O |
| High bleeding risk | O+A+P for 1 mo. | A/P+O up to 12 mo. | O+A+P < 1w | A/P+O until 12 mo. | O | |
| JCS2013 AF | / | Triple therapy may be considered | / | / | / | / |
| TSC2018 NSTEMI | CHA2DS2-VASc≥2 | O+A+P for 1–6 mo. (a) | / | / | / | O |
| High bleeding risk | / | P+O for 12 mo. | / | / | O | |
| high ischaemic risk | O+A+P for 1–6 mo. | P+O > 12 mo. | / | / | O | |
| TSC2016 AF | / | O+A+P for 3–6 mo. | P+O up to 12 mo. | O+A+P for 1 mo. | P+O up to 12 mo. | O |
| High bleeding risk | / | P+O for 12 mo. | O+A+P < 1 mo. | P+O for 3–6 mo. | O | |
[i] V = Vitamin K Antagonists; N = non-VKA oral anticoagulants; O = Oral anticoagulants; A = aspirin; P = P2Y12 inhibitor; a Bare metal stents; b drug eluting stent; ACS: acute coronary syndrome; CCS: chronic coronary syndrome; PCI: Percutaneous coronary intervention.
Figure 2
Rader charts of the AGREE II score distribution across 6 domains for the guidelines. ESC, European Society of Cardiology; NICE, National Institute for Health and Care Excellence; AHA, American Heart Association; CCS, Canadian Cardiovascular Society; JCS, Japanese Circulation Society; NHFA, National Heart Foundation of Australia; TSC, Taiwan Society of Cardiology; D1, Scope and Purpose; D2, Stakeholder Involvement; D3, Rigor of Development; D4, Clarity of Presentation; D5, Applicability; D6, Editorial Independence.
Figure 3
Flowcharts for the controversial clinical scenarios. O, Oral anticoagulation; A, Aspirin; P, P2Y12 inhibitor.