p.108 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e108

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

agents with a long record of safety (eg, flecainide and sotalol) with appropriate monitoring that includes surveillance ECGs.1,12 Amiodarone is generally avoided and reserved for life-threatening arrhythmias because of potential toxicities to the fetus, including goiter, neurodevelopmental abnormalities, bradycardia, delayed growth, and premature birth.10,12

4 In pregnant individuals with persistent AF, rate-

control strategies may include beta blockers with long record of safety in pregnancy (propranolol, metoprolol) or digoxin. Atenolol is generally avoided in pregnancy due to concerns about intrauterine growth retardation. Serum digoxin levels may be unreliable in pregnancy as digoxin-like immunoreactive substances are increased in pregnant individuals and react with antibodies against digoxin, interfering with the radioassay used for detection of digoxin serum levels.13

5 Tools available to predict stroke risk in AF have not

been validated in pregnancy. In the rare case of AF with no risk factors or signs of heart disease, anticoagulation may not be necessary.1,14 SDM should be used when considering anticoagulation during pregnancy (Table 28). Some patients may be deemed at high risk for stroke, such as those with mitral stenosis, for which recommendations for anticoagulation in pregnancy are extrapolated from experience in managing VHD. Warfarin may be administered in the first trimester providing the dose needed to achieve a therapeutic INR is ≤5 mg. If the dose of warfarin is >5 mg/day, low-molecular-weight heparin should be administered throughout the first trimester and then transitioned to warfarin for the remainder of the antenatal period until 36 hours before a planned delivery, at which time unfractionated heparin is started.15 Vaginal delivery should be advised for most women, and VKAs are generally held to mitigate risk of bleeding compliciations.13 Use of novel DOACs is not recommended during pregnancy in view of lack of evidence about safety.16

10.14 Cardio-Oncology and Anticoagulation

Considerations Recommendations for Cardio-Oncology and Anticoagulation Considerations Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 C-LD 1 In patients with cancer and AF, multidisciplinary com-

munication including cardiology, oncology and other clinicians, and SDM with the patient is recommended to optimize cancer and AF treatment and to reduce the risk of drug-drug interactions, QTc prolongation, proarrhythmia, bleeding, and thromboembolism.1–3

2a C-LD 2 In patients who are to be initiated on cancer

therapies associated with an increased risk of developing AF, increased vigilance for incident AF and treatment of contributing factors is reasonable to decrease morbidity.1,4–6

2a B-NR 3 In most patients with AF and cancer (remote

history or receiving active cancer treatment), DOACs are reasonable to choose over VKAs for stroke risk reduction.7,8

Synopsis Patients with cancer have an increased risk of AF. A Danish nationwide study observed an incident AF rate of 17.4 per 1000 person-years compared with 3.7 per 1000 person-years in patients without cancer.9 A meta-analysis of observational studies demonstrated the risk of AF to be ∼47% higher in patients with cancer compared with patients without cancer.5,10 The increased risk of AF is likely related to increased age, shared risk factors between cancer and CVD (eg, obesity and systemic inflammation), coexistent comorbidities (eg, hypertension and HF), cardiac involvement by the tumor, as well as certain medical therapeutics (Table 29), oncologic surgery, especially thoracic, and thoracic radiation therapy.11,12 New-onset AF in patients with cancer is associated with a higher risk of HF, thromboembolism, bleeding, and mortality.13–15 Notably, Bruton’s tyrosine kinase (BTK) inhibitors, such as ibrutinib, which are used to treat chronic lymphocytic leukemia and lymphoproliferative malignancies and often used for an extended period of time, are associated with a higher risk of AF due to off-target cardiac effects.16 In 1 metaanalysis, the risk of AF with use of ibrutinib was 4 times higher compared with that without use of ibrutinib.17 Although patients with cancer are underrepresented in the major trials comparing DOACs to VKAs, large observational studies and meta-analyses of studies of patients with cancer and AF have demonstrated similar or lower rates of ischemic stroke and bleeding in patients taking DOACs compared with warfarin.7,8 Patients with

Table 28.  Anticoagulation Strategies During Pregnancy Antenatal Options

Method 1 Method 2 Method 3 Alternative Method 4

First trimester Warfarin ≤5 mg LMWH UFH LMWH Second trimester Warfarin Warfarin Warfarin LMWH Third trimester Warfarin Warfarin Warfarin LMWH Delivery Planning

Method 1 Method 2

1 wk before Discontinue warfarin → continuous IV UFH Dose-adjusted LMWH 36 h before Continuous IV UFH Switch to continuous IV UFH 4-6 h before Stop IV heparin Stop IV heparin Adapted with permission from Otto et al.15 Copyright 2021 American Heart Association, Inc., and American College of Cardiology Foundation. IV indicates intravenous; LMWH, low-molecular-weight heparin; and UFH, unfractionated heparin. Downloaded from http://ahajournals.org by on October 7, 2026