ACC-AHA 2023 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.33 | 1 A | S2 Thromboembolism Either an ischemic stroke, transient ischemic attack, peripheral embolism, or pulmonary embolism Downloaded from http://ahajournals.org by on October 7, 2026 V Vascular Disease Coronary artery disease (prior myocardial infarction, angina pectoris, percutaneous coronary intervention, or coronary artery bypass surgery) or peripheral vascular disease (the presence of any of the following: intermittent claudication, previous surgery or percutaneous intervention on the abdominal aorta or the lower extremity vessels, abdominal or thoracic vascular surgery, arterial and venous thrombosis) A Age standard risk/ weight Age 65–74 y Sc Sex Category Female sex Modified with permission from Lip et al.2 Copyright 2010, with permission from Elsevier. | ||
| p.33 | 1 A | patients with AF and moderate-severe rheumatic mitral stenosis or mechanical heart valves. Clinical studies show that the target INR is between 2 and 3, and risk of bleeding becomes mostly apparent when INR exceeds 4. OAC use in special populations will be discussed in separate sections. Table 11. Additional Risk Factors That Increase Risk of Stroke Not Included in CHA2DS2-VASc Higher AF burden/Long duration Persistent/permanent AF versus paroxysmal Obesity (BMI, ≥30 kg/m2) HCM Poorly controlled hypertension | ||
| p.43 | 1 A | Bleeding related to isolated trauma Spontaneous intracranial/ intraspinal bleeding due to a nonreversible cause Bleeding related to procedural complications Serious bleeding related to recurrent falls when cause of falls is not felt to be treatable surgery or major endovascular intervention).7 Registry data have shown substantial variation in postprocedure antithrombotic regimens in realworld practice compared with protocols in the pivotal RCTs; the effect this has on long-term outcomes has not been clearly established.8 ASAP- TOO (Assessment of the Watchman Device in Patients Unsuitable for Oral Anticoagulation) is an ongoing RCT evaluating the safety and efficacy of LAAO in patients with AF who are deemed ineligible for oral anticoagulation.9 | ||
| p.43 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 2 PROTECT AF (Watchman Left Atrial Appendage | ||
| p.50 | 1 A | CLINICAL STATEMENTS AND GUIDELINES | ||
| p.52 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 agulation after surgery is a complex decision that should integrate patient and surgical characteristics. Warfarin, which takes several days (usually 3-5) to become therapeutic, can often be restarted the evening of the procedure. Postoperative bridging anticoagulation has not been shown to be generally beneficial.1,13 In the PAUSE study, DOACs were started on the first postoperative day for low bleeding risk procedures and between the evening of the second and third postoperative days for high bleeding risk procedures. This resulted in a low risk of major bleeding.4 Input from the proceduralist should always be incorporated into decisions. 6. Several studies have compared a strategy of | ||
| p.52 | 1 A | bridging anticoagulation with a comparator of no bridging in patients on anticoagulants who were scheduled to undergo an invasive procedure or surgery. The BRIDGE trial randomized 1 884 patients with AF or AFL to bridging anticoagulation before and after the procedure with dalteparin versus placebo.1 Almost 90% of patients were undergoing | ||
| p.79 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.84 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.86 | 1 A | to progression and higher AF burden associated with worse clinical outcomes.31–39 In patients with subclinical AF <24 hours, progression to overt AF or episodes >24 hours occurs at a rate of 8.8% per year, and those patients who develop AF are more likely to be hospitalized for HF.56 Several observational studies have reported AF progression may be improved by using a catheter-based ablation rhythm-control strategy.33–35,37,38 As an example, in 1 randomized trial that was stopped prematurely, in 255 patients with paroxysmal AF randomized to catheter ablation or antiarrhythmic medication, freedom from persistent AF or AT was significantly higher with catheter ablation (ablation: 2.4%, versus antiarrhythmic medication, 17.5%, 1-sided P=0.0009).57 However, serious adverse events associated with the ablation were observed in 8% of patients.57 Despite the potential risks associated with catheter ablation, in a recent analysis of a large registry that specifically evaluated asymptomatic patients, rhythm control was associated with an improvement in the composite outcome of cardiac death, ischemic stroke, and hospitalization for HF.58 The impact was largest in those patients who underwent catheter ablation for rhythm control, particularly in those with paroxysmal AF, LA diameters ≤50 mm,58 or higher stroke risk (CHA2DS2-VASc score ≥3). In a post hoc analysis of EAST-AFNET 4, the magnitude of benefit from a rhythm-control strategy for reducing the primary composite outcome of cardiovascular death, stroke, or hospitalizations for HF or ACS was independent of symptom status, and catheter ablation for rhythm control was used in approximately 20% of patients, whether symptomatic or not.59 Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.88 | 1 A | CLINICAL STATEMENTS AND GUIDELINES Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.89 | 1 A | 8.4.5. Complications After AF Catheter Ablation Complications of AF catheter ablation occur in approximately 5% of patients, with most being vascular (Table 26).1–4 However, several life-threatening complications may occur. Complications are more common with annual operator procedures <25 patients and hospital procedures <50 patients.1 Some studies demonstrate a higher incidence of complications in wom- | ||
| p.92 | 1 A | CLINICAL STATEMENTS AND GUIDELINES |