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      2020 Asian Pacific Society of Cardiology Consensus Recommendations on Antithrombotic Management for High-risk Chronic Coronary Syndrome

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          Abstract

          The unique characteristics of patients with chronic coronary syndrome (CCS) in the Asia-Pacific region, heterogeneous approaches because of differences in accesses and resources and low number of patients from the Asia-Pacific region in pivotal studies, mean that international guidelines cannot be routinely applied to these populations. The Asian Pacific Society of Cardiology developed these consensus recommendations to summarise current evidence on the management of CCS and provide recommendations to assist clinicians treat patients from the region. The consensus recommendations were developed by an expert consensus panel who reviewed and appraised the available literature, with focus on data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting recommendations provide guidance on the assessment and management of bleeding and ischaemic risks in Asian CCS patients. Furthermore, the selection of long-term antithrombotic therapy is discussed, including the role of single antiplatelet therapy, dual antiplatelet therapy and dual pathway inhibition therapy.

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          Most cited references51

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          2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes

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            GRADE guidelines: 3. Rating the quality of evidence.

            This article introduces the approach of GRADE to rating quality of evidence. GRADE specifies four categories-high, moderate, low, and very low-that are applied to a body of evidence, not to individual studies. In the context of a systematic review, quality reflects our confidence that the estimates of the effect are correct. In the context of recommendations, quality reflects our confidence that the effect estimates are adequate to support a particular recommendation. Randomized trials begin as high-quality evidence, observational studies as low quality. "Quality" as used in GRADE means more than risk of bias and so may also be compromised by imprecision, inconsistency, indirectness of study results, and publication bias. In addition, several factors can increase our confidence in an estimate of effect. GRADE provides a systematic approach for considering and reporting each of these factors. GRADE separates the process of assessing quality of evidence from the process of making recommendations. Judgments about the strength of a recommendation depend on more than just the quality of evidence. Copyright © 2011 Elsevier Inc. All rights reserved.
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              Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.

              Contemporary clinical risk stratification schemata for predicting stroke and thromboembolism (TE) in patients with atrial fibrillation (AF) are largely derived from risk factors identified from trial cohorts. Thus, many potential risk factors have not been included. We refined the 2006 Birmingham/National Institute for Health and Clinical Excellence (NICE) stroke risk stratification schema into a risk factor-based approach by reclassifying and/or incorporating additional new risk factors where relevant. This schema was then compared with existing stroke risk stratification schema in a real-world cohort of patients with AF (n = 1,084) from the Euro Heart Survey for AF. Risk categorization differed widely between the different schemes compared. Patients classified as high risk ranged from 10.2% with the Framingham schema to 75.7% with the Birmingham 2009 schema. The classic CHADS(2) (Congestive heart failure, Hypertension, Age > 75, Diabetes, prior Stroke/transient ischemic attack) schema categorized the largest proportion (61.9%) into the intermediate-risk strata, whereas the Birmingham 2009 schema classified 15.1% into this category. The Birmingham 2009 schema classified only 9.2% as low risk, whereas the Framingham scheme categorized 48.3% as low risk. Calculated C-statistics suggested modest predictive value of all schema for TE. The Birmingham 2009 schema fared marginally better (C-statistic, 0.606) than CHADS(2). However, those classified as low risk by the Birmingham 2009 and NICE schema were truly low risk with no TE events recorded, whereas TE events occurred in 1.4% of low-risk CHADS(2) subjects. When expressed as a scoring system, the Birmingham 2009 schema (CHA(2)DS(2)-VASc acronym) showed an increase in TE rate with increasing scores (P value for trend = .003). Our novel, simple stroke risk stratification schema, based on a risk factor approach, provides some improvement in predictive value for TE over the CHADS(2) schema, with low event rates in low-risk subjects and the classification of only a small proportion of subjects into the intermediate-risk category. This schema could improve our approach to stroke risk stratification in patients with AF.
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                Author and article information

                Journal
                Eur Cardiol
                Eur Cardiol
                ECR
                European Cardiology Review
                Radcliffe Cardiology
                1758-3756
                1758-3764
                18 June 2021
                February 2021
                : 16
                : e26
                Affiliations
                [1. ] National Heart Centre Singapore
                [2. ] Sengkang General Hospital Singapore
                [3. ] College of Medicine and Public Health, Flinders University Adelaide, Australia
                [4. ] Concord Repatriation General Hospital, University of Sydney Sydney, Australia
                [5. ] McMaster University Ontario, Canada
                [6. ] Sorbonne University Paris, France
                [7. ] ACTION Study Group France
                [8. ] Pitié-Salpêtrière University Hospital (AP-HP) Paris, France
                [9. ] Kitasato University and Hospital Kanagawa, Japan
                [10. ] Yonsei University College of Medicine South Korea
                [11. ] Pantai Hospital Kuala Lumpur Kuala Lumpur, Malaysia
                [12. ] University of Sydney Sydney, Australia
                [13. ] Westmead Applied Research Centre, University of Sydney Sydney, Australia
                [14. ] Westmead Hospital Sydney, Australia
                [15. ] Calmette Hospital Phnom Penh, Cambodia
                [16. ] Queen Mary Hospital, University of Hong Kong Hong Kong, China
                [17. ] Batra Hospital and Medical Research Center New Delhi, India
                [18. ] Faculty of Medicine, University of Indonesia Jakarta, Indonesia
                [19. ] Wakayama Medical University Wakayama, Japan
                [20. ] Changi General Hospital Singapore
                [21. ] Singapore General Hospital Singapore
                [22. ] MacKay Memorial Hospital, MacKay Medical College Taipei, Taiwan
                [23. ] King Chulalongkorn Memorial Hospital Bangkok, Thailand
                [24. ] Siriraj Hospital, Mahidol University Bangkok, Thailand
                [25. ] Heart & Vascular Institute, Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates
                [26. ] University of Edinburgh Edinburgh, UK
                [27. ] Hanoi Medical University, Vietnam National Heart Institute Hanoi, Vietnam
                [28. ] Liverpool Hospital Sydney, Australia
                Author notes

                Disclosure: This work was funded through the Asian Pacific Society of Cardiology with unrestricted educational grants from Abbott Vascular, Amgen, AstraZeneca, Bayer and Roche Diagnostics. JWCT reports honoraria from AstraZeneca, Bayer, Amgen, Medtronic, Abbott Vascular, Biosensors, Alvimedica, Boehringer Ingelheim and Pfizer; research and educational grants from Medtronic, Biosensors, Biotronik, Philips, Amgen, AstraZeneca, Roche, Otsuka, Terumo and Abbott Vascular; and consulting fees from Elixir and CSL Behring. DPC reports consulting fees from the Asian Pacific Society of Cardiology (APSC); support for travel to meetings for the study or otherwise from APSC; grants/grants pending from Roche Diagnostics; and payment for development of educational presentations, including service on speakers’ bureaus from AstraZeneca. DB reports honoraria from AstraZeneca, Bristol-Myers Squibb and Pfizer. JA reports honoraria from AstraZeneca, Daiichi Sankyo, Bayer and Sanofi; and grants/grants pending from Daiichi Sankyo. GM reports research grants to the Institution or consulting/lecture fees from Abbott, Amgen, Actelion, American College of Cardiology Foundation, AstraZeneca, Axis-Santé, Bayer, Boston Scientific, Boehringer Ingelheim, Bristol-Myers Squibb, Beth Israel Deaconess Medical, Brigham Women’s Hospital, Idorsia, Elsevier, Fédération Française de Cardiologie, Frequence Medicale, ICAN, Lead-Up, Medtronic, Menarini, MSD, Pfizer, Quantum Genomics, Sanofi, SCOR Global Life, Servier and WebMD. DKQ reports honoraria from Bayer and Pfizer. HFT reports research grants or consulting/lecture fees from Abbott, Amgen, AstraZeneca, Bayer, Boston Scientific, Boehringer Ingelheim, Biosense Webster, Daiichi Sankyo, Pfizer, Sanofi and Servier. KAAF reports research grants from Bayer and AstraZeneca; and consulting/lecture fees from Bayer/Janssen, Sanofi/Regeneron and Verseon. SJA reports honoraria from Bayer. CKC reports speaker or advisory attracting travel expenses or honoraria from Amgen, AstraZeneca and Bayer. SL reports lecture honoraria from Bristol-Myers Squibb, Bayer and Boehringer-Ingelheim; proctorship fees from Abbott, Boston Scientific and Bioexcel; research funding from Abbot; and is an advisory board member for Abbott and Medtronic. HIY has been a speaker for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Lilly, Mitsubishi Tanabe, Novartis, MSD, Orient Europharma, Pfizer and Sanofi. All other authors have no conflicts of interest to declare.

                Correspondence: Jack Wei Chieh Tan, National Heart Centre, 5 Hospital Dr, Singapore 169609. E: jack.tan.w.c@ 123456singhealth.com.sg
                Article
                10.15420/ecr.2020.45
                8251506
                34249148
                c6df7799-d382-4052-94ea-f92e62139681
                Copyright © 2021, Radcliffe Cardiology

                This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

                History
                : 24 November 2020
                : 22 March 2021
                Page count
                Pages: 8
                Categories
                APSC Consensus Recommendations

                asia-pacific,chronic coronary syndrome,ischaemia,antiplatelet,anticoagulant,bleeding,consensus

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