p.47 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e47

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

and lower risk of volume overload (2.1% versus 8.8%; OR, 0.27 [95% CI, 0.13-0.58]) compared with fresh frozen plasma. No significant difference in thromboembolic events (4.2% versus 4.8%; OR, 0.91 [95% CI, 0.44-1.89]; P=0.81) was found. 5.	 A meta-analysis of 10 cohort studies compared

anticoagulation resumption (n=2080) versus discontinuation (n=2296) after gastrointestinal bleeding in patients receiving OACs for AF, venous thromboembolism, or prosthetic valve.11 Restarting anticoagulation was significantly associated with higher risks of recurrent gastrointestinal bleeding (10.1% versus 5.3%) but also with lower risks of thromboembolic events (6.3% versus 10.6% ) and a reduction in all-cause mortality (21.3% versus 31%). Another meta-analysis of 7 observational studies in patients with AF found no significant difference in stroke rates between resumption and discontinuation groups (9.1% versus 8.3%; OR, 0.75 [95% CI, 0.37- 1.51]).12 Resumption of anticoagulation therapy was associated with significant reduction in any thromboembolic events (8.0% versus 12.2%; OR, 0.54 [95% CI, 0.43-0.68]) and all-cause mortality (10.8% absolute risk reduction; OR, 0.38 [95% CI, 0.24-0.60]), at the expense of recurrent major bleeding (10.2% versus 5.0%). One study found the optimal timing of resuming a VKA after upper gastrointestinal bleeding was between 3 and 6 weeks, while other studies revealed that resuming a VKA 1 week after gastrointestinal bleeding is the optimal timing.19–21 There is a paucity of data evaluating the timing of DOACs after gastrointestinal bleeding.

6.6.1 Management of Patients With AF and ICH

Recommendations for Management of Patients With AF and ICH Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

2a C-LD 1 In patients with AF and conditions associated with

very high risk of thromboembolic events (>5%/year), such as rheumatic heart disease or a mechanical heart valve, early (1-2 weeks) resumption of anticoagulation after ICH is reasonable to reduce the risk of thromboembolic events.1

2b C-LD 2 In patients with AF and ICH, delayed (4-8 weeks)

resumption of anticoagulation may be considered to balance the risks of thromboembolic and hemorrhagic complications after careful risk benefit assessment.2–5

2b B-NR 3 In patients with AF and conditions associated with

high risk of recurrent ICH (eg, cerebral amyloid angiopathy) anticoagulation-sparing strategies (eg, LAAO) may be considered to reduce the risk of recurrent hemorrhage.6,7

Synopsis ICH is a term that refers to bleeding within any of the compartments of the cranial vault, including intraparenchymal

Table 16.  Bleeding Events (Percentage Per Year) in DOAC Pivotal Clinical Trials

Bleeding Event RE-LY (n=18 113) ARISTOTLE (n=18 201) ENGAGE AF-TIMI 48 (n=21 105) ROCKET AF (n=14 264) Major bleeding Dabigatran 150 mg 3.11% (RR, 0.93 [95% CI, 0.81– 1.07]; P=0.31) Dabigatran 110 mg 2.71% (RR, 0.80 [95% CI, 0.69– 0.93]; P=0.003) Warfarin 3.36% Apixaban 2.13% (HR, 0.69 [95% CI, 0.60–0.80]; P<0.001) Warfarin 3.09% Edoxaban 60 mg 2.75% vs warfarin 3.43% (HR, 0.80 [95% CI, 0.71–0.91]; P<0.001) Edoxaban 30 mg 1.61% vs warfarin 3.43% (HR, 0.47 [95% CI, 0.41–0.55]; P<0.001) Rivaroxaban 3.6% vs warfarin 3.4% (HR, 1.04 [95% CI, 0.90–1.20]; P=0.58) Gastrointestinal bleeding Dabigatran 150 mg 1.51% vs warfarin 1.02% (RR, 1.50 [95% CI, 1.19–1.89]; P<0.001) Dabigatran 110 mg 1.12% vs warfarin 1.02% (RR, 1.10 [95% CI, 0.86–1.41]; P=0.43) Apixaban 0.76% (HR, 0.89 [95% CI, 0.70–1.15]; P=0.37) Warfarin 0.86% Edoxaban 60 mg 1.51% (HR, 1.23 [95% CI, 1.02–1.50] ; P=0.03) Edoxaban 30 mg 0.82% (HR, 0.67 [95% CI, 0.53–0.83]; P<0.001) Warfarin 1.23% Rivaroxaban 3.2% (HR not reported; P<0.001) Warfarin 2.2% Intracranial bleeding Dabigatran 150 mg 0.30% (RR, 0.40 [95% CI, 0.27– 0.60]; P<0.001) Dabigatran 110 mg 0.23% (RR, 0.31 [95% CI, 0.20– 0.47]; P<0.001) Warfarin 0.74% Apixaban 0.33% (HR, 0.42 [95% CI, 0.30–0.58]; P<0.001) Warfarin 0.80% Edoxaban 60 mg 0.39% (HR, 0.47 [95% CI, 0.34–0.63]; P<0.001) Edoxaban 30 mg 0.26% (HR, 0.30 [95% CI, 0.21–0.43]; P<0.001) Warfarin 0.85% Rivaroxaban 0.80% (HR, 0.67 [95% CI, 0.47–0.93]; P=0.02) Warfarin 1.20% Adapted with permission from Kido et al.22 Copyright 2021 American College of Clinical Pharmacy. ARISTOTLE indicates Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation; DOAC, direct anticoagulant; ENGAGE AF-TIMI 48, Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation – Thrombolysis in Myocardial Infarction 48; HR indicates hazard ratio; RE-LY, Randomized Evaluation of Long-Term Anticoagulation Therapy; ROCKET AF, Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation; and RR, relative risk.

Downloaded from http://ahajournals.org by on October 7, 2026