From the Department of Medicine, California Pacific Medical Center, San Francisco, CA.
Department of Medicine, New York Medical College, Westchester Medical Center, Valhalla, NY.
Cardiol Rev. 2020 Jul/Aug;28(4):190-196. doi: 10.1097/CRD.0000000000000288.
Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. In western countries with aging populations, atrial fibrillation poses a significant health concern, as it is associated with a high risk of thromboembolism, stroke, congestive heart failure, and myocardial infarction. Thrombi are generated in the left atrial appendage, and subsequent embolism into the cerebral circulation is a major cause of ischemic stroke. Therefore, patients have a lifetime risk of stroke, and those at high risk, defined as a CHA2DS2-VASc2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, age 65-74 yrs, sex category) ≥2, are usually placed on oral anticoagulants. Unfortunately, long-term anticoagulation poses bleeding risks, of which intracranial hemorrhage (ICH) is the most feared and deadly complication.In patients who survive an ICH, the question of oral anticoagulation resumption arises. It is a therapeutic dilemma in which clinicians must decide how to manage the risk of thromboembolism versus recurrent hemorrhage. Although there is a substantial amount of retrospective data on the topic of resumption of anticoagulation, there are, at this time, no randomized controlled trials addressing the issue. We therefore sought to address ICH risk and management, summarize high quality existing evidence on restarting oral anticoagulation, and suggest an approach to clinical decision-making.
心房颤动是普通人群中最常见的持续性心律失常。在人口老龄化的西方国家，心房颤动是一个重大的健康问题，因为它与血栓栓塞、中风、充血性心力衰竭和心肌梗死的风险增加有关。血栓形成于左心耳，随后栓塞进入脑循环是缺血性中风的主要原因。因此，患者终生存在中风风险，那些被定义为 CHA2DS2-VASc2（充血性心力衰竭、高血压、年龄>75 岁、糖尿病、中风/短暂性脑缺血发作/血栓栓塞、血管疾病、年龄 65-74 岁、性别）≥2 的高危患者通常需要口服抗凝剂。不幸的是，长期抗凝会带来出血风险，其中颅内出血（ICH）是最令人恐惧和致命的并发症。在幸存 ICH 的患者中，会出现是否恢复口服抗凝的问题。这是一个治疗上的困境，临床医生必须决定如何管理血栓栓塞的风险与再次出血的风险。尽管关于恢复抗凝的主题有大量回顾性数据，但目前尚无随机对照试验来解决这个问题。因此，我们试图解决 ICH 风险和管理问题，总结有关重新开始口服抗凝的高质量现有证据，并提出一种临床决策方法。
