Interpretation of the assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A position paper from ESC/EHRA/AACA/APHRS_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LUO Chong , BIAN Longrong ,  WU Zhong

Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding author：

WU Zhong, Email: wuzhong71@163.com

Keywords：

Atrial fibrillation; oral anticoagulants; drug-related bleeding; position paper interpretation

DOI：

10.7507/1007-4848.202204059

Video：

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Atrial fibrillation is now the most frequent kind of adult arrhythmia in the world, with a prevalence rate at 2%-4%. In addition to the clinical symptoms of palpitation, shortness of breath, chest tightness, and decreased exercise tolerance, patients with atrial fibrillation have a 4 to 5 times higher risk of ischemic stroke than patients without atrial fibrillation, so anticoagulation therapy should be tailored to the CHA2DS2-VASc [congestive heart failure, hypertension, age≥75 years (doubled), diabetes mellitus, stroke (doubled)-vascular disease, age 65-74 years and sex category (female)] score. Oral anticoagulants not only prevent thrombosis, but also raise the risk of drug-related bleeding. This paper examines the assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A position paper from ESC/EHRA/AACA/APHRS, in order to provide readers with the most up-to-date research on anticoagulant bleeding risk management in patients with atrial fibrillation.

Citation： LUO Chong, BIAN Longrong, WU Zhong. Interpretation of the assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A position paper from ESC/EHRA/AACA/APHRS. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(7): 812-819. doi: 10.7507/1007-4848.202204059 Copy

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9.	Alatri A, Mazzolai L, Kucher N, et al. The modified Ottawa score and clinical events in hospitalized patients with cancer-associated thrombosis from the Swiss VTE Registry. Semin Thromb Hemost, 2017, 43(8): 871-876.
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12.	Walters TE, Wick K, Tan G, et al. Symptom severity and quality of life in patients with atrial fibrillation: Psychological function outweighs clinical predictors. Int J Cardiol, 2019, 279: 84-89.
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18.	Chiang CE, Okumura K, Zhang S, et al. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation. J Arrhythm, 2017, 33(4): 345-367.
19.	王清华, 刘烨, 张桂林, 等. 输入时滞非线性系统的新型动态面Funnel控制. 控制理论与应用, 2022: 1-7. [Epub ahead of print].
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26.	Vemulapalli S, Hellkamp AS, Jones WS, et al. Blood pressure control and stroke or bleeding risk in anticoagulated patients with atrial fibrillation: Results from the ROCKET AF trial. Am Heart J, 2016, 178: 74-84.
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28.	Park S, Bergmark BA, Shi M, et al. Edoxaban versus warfarin stratified by average blood pressure in 19 679 patients with atrial fibrillation and a history of hypertension in the ENGAGE AF-TIMI 48 Trial. Hypertension, 2019, 74(3): 597-605.
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37.	Fye WB. Heparin: The contributions of William Henry Howell. Circulation, 1984, 69(6): 1198-1203.
38.	Link KP. The discovery of dicumarol and its sequels. Circulation, 1959, 19(1): 97-107.
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1. Lip GYH. The ABC pathway: An integrated approach to improve AF management. Nat Rev Cardiol, 2017, 14(11): 627-628.
2. Shi S, Tang Y, Zhao Q, et al. Prevalence and risk of atrial fibrillation in China: A national cross-sectional epidemiological study. (2021).
3. Lutsey PL, Horvath KJ, Fullam L, et al. Anticoagulant preferences and concerns among venous thromboembolism patients. Thromb Haemost, 2018, 118(3): 553-561.
4. Paciaroni M, Agnelli G, Micheli S, et al. Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: A meta-analysis of randomized controlled trials. Stroke, 2007, 38(2): 423-430.
5. Saxena R, Lewis S, Berge E, et al. Risk of early death and recurrent stroke and effect of heparin in 3169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial. Stroke, 2001, 32(10): 2333-2337.
6. Bekwelem W, Connolly SJ, Halperin JL, et al. Extracranial systemic embolic events in patients with nonvalvular atrial fibrillation: Incidence, risk factors, and outcomes. circulation, 2015, 132(9): 796-803.
7. Ruíz-Giménez N, Suárez C, González R, et al. Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost, 2008, 100(1): 26-31.
8. Noble S, Matzdorff A, Maraveyas A, et al. Assessing patients' anticoagulation preferences for the treatment of cancer-associated thrombosis using conjoint methodology. Haematologica, 2015, 100(11): 1486-1492.
9. Alatri A, Mazzolai L, Kucher N, et al. The modified Ottawa score and clinical events in hospitalized patients with cancer-associated thrombosis from the Swiss VTE Registry. Semin Thromb Hemost, 2017, 43(8): 871-876.
10. Blum S, Muff C, Aeschbacher S, et al. Prospective assessment of sex-related differences in symptom status and health perception among patients with atrial fibrillation. J Am Heart Assoc, 2017, 6(7): e005401.
11. Freeman JV, Simon DN, Go AS, et al. Association between atrial fibrillation symptoms, quality of life, and patient outcomes: Results from the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF). Circ Cardiovasc Qual Outcomes, 2015, 8(4): 393-402.
12. Walters TE, Wick K, Tan G, et al. Symptom severity and quality of life in patients with atrial fibrillation: Psychological function outweighs clinical predictors. Int J Cardiol, 2019, 279: 84-89.
13. Lip GY, Lane DA. Bleeding risk assessment in atrial fibrillation: Observations on the use and misuse of bleeding risk scores. J Thromb Haemost, 2016, 14(9): 1711-1714.
14. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J, 2016, 37(38): 2893-2962.
15. Guo Y, Lane DA, Wang L, et al. Mobile health technology to improve care for patients with atrial fibrillation. J Am Coll Cardiol, 2020, 75(13): 1523-1534.
16. Lip GY, Nieuwlaat R, Pisters R, 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, 2010, 137(2): 263-272.
17. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J, 2021, 42(5): 373-498.
18. Chiang CE, Okumura K, Zhang S, et al. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation. J Arrhythm, 2017, 33(4): 345-367.
19. 王清华, 刘烨, 张桂林, 等. 输入时滞非线性系统的新型动态面Funnel控制. 控制理论与应用, 2022: 1-7. [Epub ahead of print].
20. Gorog DA, Gue YX, Chao TF, et al. Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A position paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society. Europace, 2022: euac020.
21. Bovill EG, Terrin ML, Stump DC, et al. Hemorrhagic events during therapy with recombinant tissue-type plasminogen activator, heparin, and aspirin for acute myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI), phase Ⅱ trial. Ann Intern Med, 1991, 115(4): 256-265.
22. GUSTO investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med, 1993, 329(10): 673-682.
23. Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: A consensus report from the Bleeding Academic Research Consortium. Circulation, 2011, 123(23): 2736-2747.
24. Chao TF, Lip GYH, Lin YJ, et al. Incident risk factors and major bleeding in patients with atrial fibrillation treated with oral anticoagulants: A comparison of baseline, follow-up and delta has-bled scores with an approach focused on modifiable bleeding risk factors. Thromb Haemost, 2018, 118(4): 768-777.
25. Du H, Wilson D, Ambler G, et al. Small vessel disease and ischemic stroke risk during anticoagulation for atrial fibrillation after cerebral ischemia. Stroke, 2021, 52(1): 91-99.
26. Vemulapalli S, Hellkamp AS, Jones WS, et al. Blood pressure control and stroke or bleeding risk in anticoagulated patients with atrial fibrillation: Results from the ROCKET AF trial. Am Heart J, 2016, 178: 74-84.
27. Rao MP, Halvorsen S, Wojdyla D, et al. Blood pressure control and risk of stroke or systemic embolism in patients with atrial fibrillation: Results from the apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation (ARISTOTLE) Trial. J Am Heart Assoc, 2015, 4(12): e002015.
28. Park S, Bergmark BA, Shi M, et al. Edoxaban versus warfarin stratified by average blood pressure in 19 679 patients with atrial fibrillation and a history of hypertension in the ENGAGE AF-TIMI 48 Trial. Hypertension, 2019, 74(3): 597-605.
29. Kim D, Yang PS, Kim TH, et al. Ideal blood pressure in patients with atrial fibrillation. J Am Coll Cardiol, 2018, 72(11): 1233-1245.
30. Rohla M, Weiss TW, Pecen L, et al. Risk factors for thromboembolic and bleeding events in anticoagulated patients with atrial fibrillation: The prospective, multicentre observational PREvention oF thromboembolic events — European Registry in Atrial Fibrillation (PREFER in AF). BMJ Open, 2019, 9(3): e022478.
31. Hijazi Z, Oldgren J, Lindbäck J, 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, 2016, 387(10035): 2302-2311.
32. Berg DD, Ruff CT, Jarolim P, et al. Performance of the ABC Scores for assessing the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in ENGAGE AF-TIMI 48. Circulation, 2019, 139(6): 760-771.
33. Pol T, Hijazi Z, Lindbäck J, et al. Evaluation of the prognostic value of GDF-15, ABC-AF-bleeding score and ABC-AF-death score in patients with atrial fibrillation across different geographical areas. Open Heart, 2021, 8(1): e001471.
34. Esteve-Pastor MA, Rivera-Caravaca JM, Roldan V, et al. Long-term bleeding risk prediction in 'real world' patients with atrial fibrillation: Comparison of the HAS-BLED and ABC-Bleeding risk scores. The Murcia Atrial Fibrillation Project. Thromb Haemost, 2017, 117(10): 1848-1858.
35. Rivera-Caravaca JM, Marín F, Vilchez JA, et al. Refining stroke and bleeding prediction in atrial fibrillation by adding consecutive biomarkers to clinical risk scores. Stroke, 2019, 50(6): 1372-1379.
36. Wilson D, Ambler G, Shakeshaft C, et al. Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): A multicentre observational cohort study. Lancet Neurol, 2018, 17(6): 539-547.
37. Fye WB. Heparin: The contributions of William Henry Howell. Circulation, 1984, 69(6): 1198-1203.
38. Link KP. The discovery of dicumarol and its sequels. Circulation, 1959, 19(1): 97-107.
39. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med, 2007, 146(12): 857-867.
40. Higashi MK, Veenstra DL, Kondo LM, et al. Association between CYP2C9 genetic variants and anticoagulation-related outcomes during warfarin therapy. JAMA, 2002, 287(13): 1690-1698.
41. Reitsma PH, van der Heijden JF, Groot AP, et al. A C1173T dimorphism in the VKORC1 gene determines coumarin sensitivity and bleeding risk. PLos Med, 2005, 2(10): e312.
42. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med, 2011, 365(10): 883-891.
43. Avezum A, Lopes RD, Schulte PJ, et al. Apixaban in comparison with warfarin in patients with atrial fibrillation and valvular heart disease: Findings from the apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation (ARISTOTLE) trial. Circulation, 2015, 132(8): 624-632.
44. Ezekowitz MD, Nagarakanti R, Noack H, et al. Comparison of dabigatran and warfarin in patients with atrial fibrillation and valvular heart disease: The RE-LY trial (randomized evaluation of long-term anticoagulant therapy). Circulation, 2016, 134(8): 589-598.
45. Breithardt G, Baumgartner H, Berkowitz SD, et al. Clinical characteristics and outcomes with rivaroxaban vs. warfarin in patients with non-valvular atrial fibrillation but underlying native mitral and aortic valve disease participating in the ROCKET AF trial. Eur Heart J, 2014, 35(47): 3377-3385.
46. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomizsed trials. Lancet, 2014, 383(9921): 955-962.
47. López-López JA, Sterne JAC, Thom HHZ, et al. Oral anticoagulants for prevention of stroke in atrial fibrillation: Systematic review, network meta-analysis, and cost effectiveness analysis. BMJ, 2017, 359: j5058.
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Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Interpretation of the assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A position paper from ESC/EHRA/AACA/APHRS

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