medicina60巻13号

2023年12月発行

特集 一般医家のための—DOAC時代の心房細動診療 心房細動の病態と診断

出血のリスク評価

著者： 小谷英太郎¹

所属機関： ¹日本医科大学多摩永山病院循環器内科

ページ範囲：P.2244 - P.2249

Point
◎抗凝固療法開始時には，血栓塞栓症リスクと同時に出血リスクも評価する．
◎出血リスク評価はHAS-BLEDスコアを基本とする．
◎注目される重大な出血関連因子（高齢，低体重，腎機能障害，抗血小板薬併用，管理不良な高血圧）も考慮する．
◎禁忌がない限り直接作用型経口抗凝固薬（DOAC）を選択する．
◎80歳以上の高出血リスク例にはエドキサバン15 mgが使用できる．

参考文献

1）Singer DE, et al：The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med 151：297-305, 2009

2）Gage BF, et al：Validation of clinical classification schemes for predicting stroke；Results from the National Registry of Atrial Fibrillation. JAMA 285：2864-2870, 2001

3）Lip GY, et al：Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach；The Euro Heart Survey on atrial fibrillation. Chest 137：263-272, 2010

4）Gage BF, et al：Clinical classification schemes for predicting hemorrhage；Results from the National Registry of Atrial Fibrillation（NRAF）. Am Heart J 151：713-719, 2006

5）Pisters R, et al：A novel user-friendly score（HAS-BLED）to assess 1-year risk of major bleeding in patients with atrial fibrillation；The Euro Heart Survey. Chest 138：1093-1100, 2010

6）Fang MC, et al：A new risk scheme to predict warfarin-associated hemorrhage；The ATRIA（Anticoagulation and Risk Factors in Atrial Fibrillation）Study. J Am Coll Cardiol 58：395-401, 2011

7）O'Brien EC, et al：The ORBIT bleeding score；A simple bedside score to assess bleeding risk in atrial fibrillation. Eur Heart J 36：3258-3264, 2015

8）Hijazi Z, et al：The novel biomarker-based ABC（age, biomarkers, clinical history）-bleeding risk score for patients with atrial fibrillation；A derivation and validation study. Lancet 387：2302-2311, 2016

9）Lip GYH, et al：The HAS-BLED, ATRIA, and ORBIT Bleeding Scores in atrial fibrillation patients using non-vitamin K antagonist oral anticoagulants. Am J Med 131：574. e13-574. e27, 2018

10）Chichareon P, et al：Comparative validation of HAS-BLED, GARFIELD-AF and ORBIT bleeding risk scores in Asian people with atrial fibrillation treated with oral anticoagulant；A report from the COOL-AF registry. Br J Clin Pharmacol 89：2472-2482, 2023

11）Zhu W, et al：The HAS-BLED score for predicting major bleeding risk in anticoagulated patients with atrial fibrillation；A systematic review and meta-analysis. Clin Cardiol 38：555-561, 2015

12）Fox KAA, et al：Improved risk stratification of patients with atrial fibrillation；An integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation. BMJ Open 7：e017157, 2017

13）Proietti M, et al：Predicting bleeding events in anticoagulated patients with atrial fibrillation；A comparison between the HAS-BLED and GARFIELD-AF bleeding scores. J Am Heart Assoc 7：e009766, 2018

14）JCS Joint Working Group：Guidelines for pharmacotherapy of atrial fibrillation（JCS 2013）；Digest version. Circ J 78：1997-2021, 2014

15）日本循環器学会/日本不整脈心電学会合同ガイドライン：不整脈薬物治療ガイドライン（2020年改訂版）．　https://www.j-circ.or.jp/cms/wp-content/uploads/2020/01/JCS2020_Ono.pdf（2023年7月閲覧）

16）Gallego P, et al：Relation of the HAS-BLED bleeding risk score to major bleeding, cardiovascular events, and mortality in anticoagulated patients with atrial fibrillation. Circ Arrhythm Electrophysiol 5：312-318, 2012

17）Tomita H, et al：Assessment of risk factors for bleeding in Japanese patients with non-valvular atrial fibrillation receiving warfarin treatment；A subanalysis of the J-RHYTHM Registry（letter）. Int J Cardiol 201：308-310, 2015

18）Okumura K, et al：A novel risk stratification system for ischemic stroke in Japanese patients with non-valvular atrial fibrillation. Circ J 85：1254-1262, 2021

19）Kodani E, et al：Impact of blood pressure control on thromboembolism and major hemorrhage in patients with nonvalvular atrial fibrillation；A subanalysis of the J-RHYTHM Registry. J Am Heart Assoc 5：e004075, 2016

20）Ishii M, et al：Relationship of hypertension and systolic blood pressure with the risk of stroke or bleeding in patients with atrial fibrillation；The Fushimi AF Registry. Am J Hypertens 30：1073-1082, 2017

21）小谷英太郎：心房細動患者に対する血圧管理の重要性．Cardio-coagulation 7：36-41, 2020

22）Kodani E, et al：Impact of baseline blood pressure on adverse outcomes in Japanese patients with non-valvular atrial fibrillation；The J-RISK AF. Eur Heart J Open 2：oeac081, 2022

23）Kario K, et al：Home blood pressure can predict the risk for stroke/bleeding events in elderly patients with nonvalvular atrial fibrillation from the ANAFIE registry. Hypertension 79：2696-2705, 2022

24）Ruff CT, et al：Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation；A meta-analysis of randomised trials. Lancet 383：955-962, 2014

25）Kato ET, et al：Overview of oral antithrombotic treatment in elderly patients with atrial fibrillation. Ageing Res Rev 49：115-124, 2019

26）Kodani E, Akao M：Atrial fibrillation and stroke prevention：state of the art-epidemiology and pathophysiology；New risk factors, concepts and controversies. Eur Heart J Suppl 22：O1-O13, 2020

27）Yamashita T, et al：Two-year outcomes of more than 30000 elderly patients with atrial fibrillation；Results from the All Nippon AF In the Elderly（ANAFIE）Registry. Eur Heart J Qual Care Clin Outcomes 8：202-213, 2022

28）Okumura K, et al：A multicenter prospective cohort study to investigate the effectiveness and safety of apixaban in Japanese elderly atrial fibrillation patients（J-ELD AF Registry）. Clin Cardiol 43：251-259, 2020

29）Okumura K, et al：Low-dose edoxaban in very elderly patients with atrial fibrillation. N Engl J Med 383：1735-1745, 2020

30）Okumura K, et al：Oral anticoagulants in very elderly nonvalvular atrial fibrillation patients with high bleeding risks；ANAFIE Registry. JACC Asia 2：720-733, 2022