Table 3.

Recommendations/statements of stroke prevention in special scenarios and left atrial appendage occlusion

Guidelines	Advanced CKD	Advanced liver disease/liver cirrhosis	AHREs	LAAO
2017 APHRS	In patients with ESRD or dialysis, NOACs are contraindicated. Although VKA with good-quality anticoagulation control (TTR > 70%) might be useful, the data are lacking	—	—	Interventional percutaneous LAA closure with the WATCHMAN device may be considered in patients with non-valvular AF who have high risk of stroke, but major contraindications to OAC therapy Surgical excision of the LAA may be considered in patients undergoing concomitant cardiac surgery
2018 ACCP	In stage IV (CrCl 15–30 mL/min) CKD, suggesting using VKAs and selected NOACs [rivaroxaban 15 mg QD, apixaban 2.5 mg bid, edoxaban 30 mg QD, and (in USA only) dabigatran 75 mg bid] with caution, based on pharmacokinetic data In end-stage renal disease (CrCl < 15 mL/min or dialysis-dependent), suggesting using well-managed VKA with TTR >65–70%	Patients with liver function abnormalities were generally excluded from the randomized trials, and especially where there is abnormal clotting tests, such patients may be at higher risk of bleeding on VKA, possibly less so on NOACs; in cirrhotic patients, ischaemic stroke reduction may outweigh bleeding risk.	In patients with AF, prescription of OACs could be considered as a result of an individualized clinical assessment taking into account overall AHRE burden (in the range of hours rather than minutes) and specifically, the presence of AHRE >24 h, individual stroke risk (using CHA2DS2-VASc), predicted risk benefit of OACs and informed patient preferences (Ungraded consensus-based statement)	In patients with AF at high risk of ischaemic stroke who have absolute contraindications for OAC, suggesting using LAA occlusion (Weak recommendation, low quality evidence) In AF patients at risk of ischaemic stroke undergoing cardiac surgery, we suggest surgical exclusion of the LAA for stroke prevention, but the need for long-term OAC is unchanged (Weak recommendation, low quality evidence)
2019 ACC/AHA/HRS	Class IIb - For patients with AF who have a CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women and who have ESRD (CKD; CrCl <15mL/min) or are on dialysis, it might be reasonable to prescribe warfarin (INR 2.0 to 3.0) or apixaban for oral anticoagulation	–	Prospective clinical trials of prophylactic anticoagulation based on device-detected AF are under way but have not been completed Although increased duration of AHREs is associated with increased stroke risk, the threshold duration of AHREs that warrants anticoagulation is unclear Current approaches factor in the duration of device-detected AF and the patient’s stroke risk profile, bleeding risk, an preferences to determine whether to initiate long-term anticoagulation	Class IIb - Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation
2020 ESC	In patients with CrCl 15–29 mL/min, RCT-derived data on the effect of VKA or NOACs are lacking The evidence for the benefits of OAC in patients with end-stage kidney disease with CrCl ≤ 15 mL/min or on dialysis is even more limited, and to some extent controversial	Patients with hepatic dysfunction were generally excluded from the RCTs Despite the paucity of data, observational studies did not raise concerns regarding the use of NOACs in advanced hepatic disease NOACs are contraindicated in patients within Child-Turcotte-Pugh C hepatic dysfunction, and rivaroxaban is not recommended for patients in the Child-Turcotte-Pugh B or C category	The use of OAC may be considered in selected patients with longer durations of AHRE/subclinical AF (≥24 h) and an estimated high individual risk of stroke, accounting for the anticipated net clinical benefit and informed patient's preferences	Class IIb - LAA occlusion may be considered for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment Class IIb - Surgical occlusion or exclusion of the LAA may be considered for stroke prevention in patients with AF undergoing cardiac surgery

ACC/AHA/HRS, American College of Cardiology/American Heart Association/Heart Rhythm Society; ACCP, American College of Chest Physicians; AF, atrial fibrillation; AHRE, atrial high rate episode; APHRS, Asia Pacific Heart Rhythm Society; CKD, chronic kidney disease; CrCl, creatinine clearance; ESC, European Society of Cardiology; ESRD, end-stage renal disease; INR, international normalized ratio; LAAO, left atrial appendage occlusion; NOACs, non-vitamin K antagonist oral anticoagulants; OACs, oral anticoagulants; RCTs, randomized controlled trials; TTR, time in therapeutic range; VKA, vitamin K antagonist.