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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e48

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

(or intracerebral), subarachnoid, subdural, and epidural hemorrhage. In clinical practice, the different forms of ICH are often classified by mechanism and most broadly as traumatic and nontraumatic or spontaneous ICHs (Figure 14). In patients with AF and conditions associated with high-risk for thromboembolic complications (eg, mechanical valve, rheumatic valvular disease), anticoagulation is often resumed early after ICH, regardless of mechanism. For other patients with AF, decisions regarding if (and when) to resume anticoagulation after ICH requires more careful risk-benefit assessment of patient-specific clinical factors. Patients with traumatic etiologies generally have lower longterm risk of recurrent hemorrhage, and anticoagulation is generally considered safe to resume. Nontraumatic/ spontaneous etiologies (eg, hypertensive parenchymal hemorrhage, hemorrhagic transformation after isch- emic stroke, cerebral amyloid angiopathy-associated hemorrhage, chronic subdural hemorrhage) are generally associated with higher risk of recurrence. Clinical decision-making regarding the appropriateness of resumption in these patients is based largely on individual risk-benefit calculations given the lack of randomized data assessing safety and long-term outcomes. For patients with ICH deemed at high risk of recurrence, LAA closure may be a viable alternative to anticoagulation, although data on efficacy and safety are lacking in the ICH population.

Recommendation-Specific Supportive Text 1.	 Rheumatic valvular disease is associated with a

>5% per year risk of embolic events.8 In patients with mechanical heart valves, the rate can range from 4% to 23% per year depending on the type

Figure 13. Active Bleeding Associated With Oral Anticoagulant. Colors correspond to Table 2. PCC indicates prothrombin complex concentrate.

Figure 14. Forms of ICH, Classified by Mechanism. ICH indicates intracranial hemorrhage.

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