nogrЭкспериментальная и клиническая гастроэнтерологияExperimental and Clinical Gastroenterology1682-8658«Global Media Technologies»10.31146/1682-8658-ecg-231-11-178-183nogr-2981Research ArticleОБЗОРREVIEWПерсонализированный подход к выбору антикоагулянтной терапии у пациентов с фибрилляцией предсердий в особых клинических случаяхA personalized approach to the choice of anticoagulant therapy in patients with atrial fibrillation in special clinical caseshttps://orcid.org/0000-0002-5791-4677РаффС. А.RaffS. A.staraff@mail.ruПальшковаА. Д.PalshkovaA. D.noemail@neicon.ruБахчоянМ. Р.BakhchoianM. R.noemail@neicon.ruТоховаЕ. В.TokhovaE. V.noemail@neicon.ruНаучно-исследовательский институт - Краевая клиническая больница № 1 им. проф. С.В. Очаповского; Федеральное государственное бюджетное образовательное учреждение высшего образования «Кубанский государственный медицинский университет» Министерства Здравоохранения Российской ФедерацииРоссияScientific Research Institute - Ochapovsky Regional Clinical Hospital No. 1; Kuban State Medical UniversityRussian FederationФедеральное государственное бюджетное образовательное учреждение высшего образования «Кубанский государственный медицинский университет» Министерства Здравоохранения Российской ФедерацииРоссияKuban State Medical UniversityRussian FederationНаучно-исследовательский институт - Краевая клиническая больница № 1 им. проф. С.В. ОчаповскогоРоссияScientific Research Institute - Ochapovsky Regional Clinical Hospital No. 1Russian Federation202417112024011178183Copyright © Рафф С.А., Пальшкова А.Д., Бахчоян М.Р., Тохова Е.В., 20242024Рафф С.А., Пальшкова А.Д., Бахчоян М.Р., Тохова Е.В.Raff S.A., Palshkova A.D., Bakhchoian M.R., Tokhova E.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.nogr.org/jour/article/view/2981

Фибрилляция предсердий (ФП) является патологией, которая приводит к значительному повышению риска инсульта и других тромбоэмболических осложнений (ТЭО), варьирующихся по частоте встречаемости. Это обуславливает необходимость назначения антикоагулянтной терапии (АКТ) для пациентов с данной патологией. Особенности назначения АКТ с учётом рисков геморрагических и тромбоэмболических осложнений в настоящее время всё ещё является актуальным вопросом. Значительной проблемой для пациентов, получающих пероральную антикоагулянтную терапию, является желудочно-кишечное кровотечение (ЖКК). В этой статье мы рассматриваем современные данные о связи между геморрагическими осложнениями и пероральными антикоагулянтами, уделяя особое внимание рандомизированным контролируемым исследованиям, метаанализам и постмаркетинговым наблюдательным исследованиям. Мы представили краткий обзор современных знаний о факторах риска геморрагических осложнений при приёме отдельных антикоагулянтов, стратегиях профилактики, снижающих их риск.

Atrial fibrillation (AF) is a pathology that leads to a significant increase in the risk of stroke and other thromboembolic complications (TEC), varying in frequency. This necessitates the appointment of anticoagulant therapy (ACT) for patients with this pathology. The specifics of the appointment of an ACT, taking into account the risks of hemorrhagic and thromboembolic complications, is currently still an urgent issue. Gastrointestinal bleeding is a significant problem for patients receiving oral anticoagulant therapy. In this article, we review current evidence on the association between hemorrhagic complications and oral anticoagulants, focusing on randomized controlled trials, meta-analyses, and postmarketing observational studies. We have presented a brief overview of current knowledge about the risk factors for hemorrhagic complications when taking certain anticoagulants, prevention strategies that reduce their risk.

фибрилляция предсердийантикоагулянтная терапиягеморрагические осложнениятромбоэмболические осложненияновые пероральные антикоагулянтыatrial fibrillationanticoagulant therapyhemorrhagic complicationsthromboembolic complicationsnew oral anticoagulantsReferencesLippi G., Sanchis-Gomar F., Cervellin G. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge.Int J Stroke. 2021;16(2):217-221. doi: 10.1177/1747493019897870.Lippi G., Sanchis-Gomar F., Cervellin G. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge.Int J Stroke. 2021;16(2):217-221. doi: 10.1177/1747493019897870.Chugh S.S., Havmoeller R., Narayanan K. et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-847. doi: 10.1161/CIRCULATIONAHA.113.005119.Chugh S.S., Havmoeller R., Narayanan K. et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-847. doi: 10.1161/CIRCULATIONAHA.113.005119.Kornej J., Börschel C.S., Benjamin E.J., Schnabel R.B. Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights. Circ Res. 2020;127(1):4-20. doi: 10.1161/CIRCRESAHA.120.316340.Kornej J., Börschel C.S., Benjamin E.J., Schnabel R.B. Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights. Circ Res. 2020;127(1):4-20. doi: 10.1161/CIRCRESAHA.120.316340.Haijiang Dai, Quanyu Zhang, Arsalan Abu Much et al. Global, regional, and national prevalence, incidence, mortality, and risk factors for atrial fibrillation, 1990-2017: results from the Global Burden of Disease Study 2017. Eur Heart J Qual Care Clin Outcomes. 2021 Oct 28;7(6):574-582. doi: 10.1093/ehjqcco/qcaa061.Haijiang Dai, Quanyu Zhang, Arsalan Abu Much et al. Global, regional, and national prevalence, incidence, mortality, and risk factors for atrial fibrillation, 1990-2017: results from the Global Burden of Disease Study 2017. Eur Heart J Qual Care Clin Outcomes. 2021 Oct 28;7(6):574-582. doi: 10.1093/ehjqcco/qcaa061.Lloyd-Jones D.M., Wang T.J., Leip E.P. et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004;110(9):1042-1046. doi: 10.1161/01.CIR.0000140263.20897.42.Lloyd-Jones D.M., Wang T.J., Leip E.P. et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004;110(9):1042-1046. doi: 10.1161/01.CIR.0000140263.20897.42.Van Walraven C., Hart R.G., Connolly S. et al. Effect of age on stroke prevention therapy in patients with atrial fibrillation: the atrial fibrillation investigators. Stroke. 2009;40(4):1410-1416. doi: 10.1161/STROKEAHA.108.526988.Van Walraven C., Hart R.G., Connolly S. et al. Effect of age on stroke prevention therapy in patients with atrial fibrillation: the atrial fibrillation investigators. Stroke. 2009;40(4):1410-1416. doi: 10.1161/STROKEAHA.108.526988.Hernandez I. Zhang Y.,∙Saba, S Comparison of the effectiveness and safety of apixaban, dabigatran, rivaroxaban, and warfarin in newly diagnosed atrial fibrillation. Am J Cardiol. 2017; 120:1813-1819.Hernandez I. Zhang Y.,∙Saba, S Comparison of the effectiveness and safety of apixaban, dabigatran, rivaroxaban, and warfarin in newly diagnosed atrial fibrillation. Am J Cardiol. 2017; 120:1813-1819.Sitticharoenchai P., Takkavatakarn K., Boonyaratavej S. et al. Non-Vitamin K Antagonist Oral Anticoagulants Provide Less Adverse Renal Outcomes Than Warfarin In Non-Valvular Atrial Fibrillation: A Systematic Review and MetaAnalysis. J Am Heart Assoc. 2021;10(7): e019609. doi: 10.1161/JAHA.120.019609.Sitticharoenchai P., Takkavatakarn K., Boonyaratavej S. et al. Non-Vitamin K Antagonist Oral Anticoagulants Provide Less Adverse Renal Outcomes Than Warfarin In Non-Valvular Atrial Fibrillation: A Systematic Review and MetaAnalysis. J Am Heart Assoc. 2021;10(7): e019609. doi: 10.1161/JAHA.120.019609.Steffel J., Verhamme P., Potpara T.S. et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39(16):1330-1393. doi: 10.1093/eurheartj/ehy136.Steffel J., Verhamme P., Potpara T.S. et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39(16):1330-1393. doi: 10.1093/eurheartj/ehy136.Stroke Risk in Atrial Fibrillation Working Group. Independent predictors of stroke in patients with atrial fibrillation: a systematic review. Neurology. 2007;69(6):546-554. doi: 10.1212/01.wnl.0000267275. 68538.8d.Stroke Risk in Atrial Fibrillation Working Group. Independent predictors of stroke in patients with atrial fibrillation: a systematic review. Neurology. 2007;69(6):546-554. doi: 10.1212/01.wnl.0000267275. 68538.8d.Vanbeselaere V., Truyers C., Elli S., Buntinx F. et al. Association between atrial fibrillation, anticoagulation, risk of cerebrovascular events and multimorbidity in general practice: a registry-based study. BMC Cardiovasc Disord. 2016;16:61. doi: 10.1186/s12872-016-0235-1.Vanbeselaere V., Truyers C., Elli S., Buntinx F. et al. Association between atrial fibrillation, anticoagulation, risk of cerebrovascular events and multimorbidity in general practice: a registry-based study. BMC Cardiovasc Disord. 2016;16:61. doi: 10.1186/s12872-016-0235-1.Isabelle C. Van Gelder, Michiel Rienstra, Karina V. Bunting, Ruben Casado-Arroyo et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal, 2024; 00, 1-101. doi: 10.1093/eurheartj/ehae176.Isabelle C. Van Gelder, Michiel Rienstra, Karina V. Bunting, Ruben Casado-Arroyo et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal, 2024; 00, 1-101. doi: 10.1093/eurheartj/ehae176.Graham, David J. et al.Comparative Stroke, Bleeding, and Mortality Risks in Older Medicare Patients Treated with Oral Anticoagulants for Nonvalvular Atrial Fibrillation The American Journal of Medicine, Volume 132, Issue 5, 596-604.e11 doi: 10.1016/j.amjmed.2018.12.023.Graham, David J. et al.Comparative Stroke, Bleeding, and Mortality Risks in Older Medicare Patients Treated with Oral Anticoagulants for Nonvalvular Atrial Fibrillation The American Journal of Medicine, Volume 132, Issue 5, 596-604.e11 doi: 10.1016/j.amjmed.2018.12.023.Van den Bussche H., Koller D., Kolonko T. et al. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based crosssectional study in Germany. BMC Public Health. 2011;11:101. doi: 10.1186/1471-2458-11-101.Van den Bussche H., Koller D., Kolonko T. et al. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based crosssectional study in Germany. BMC Public Health. 2011;11:101. doi: 10.1186/1471-2458-11-101.Wetmore J.B., Mahnken J.D., Rigler S.K. et al. The prevalence of and factors associated with chronic atrial fibrillation in Medicare/Medicaid-eligible dialysis patients. Kidney Int. 2012;81(5):469-476. doi: 10.1038/ki.2011.416.Wetmore J.B., Mahnken J.D., Rigler S.K. et al. The prevalence of and factors associated with chronic atrial fibrillation in Medicare/Medicaid-eligible dialysis patients. Kidney Int. 2012;81(5):469-476. doi: 10.1038/ki.2011.416.Vanbeselaere V., Truyers C., Elli S. et al. Association between atrial fibrillation, anticoagulation, risk of cerebrovascular events and multimorbidity in general practice: a registry-based study. BMC Cardiovasc Disord. 2016;16:61. doi: 10.1186/s12872-016-0235-1.Vanbeselaere V., Truyers C., Elli S. et al. Association between atrial fibrillation, anticoagulation, risk of cerebrovascular events and multimorbidity in general practice: a registry-based study. BMC Cardiovasc Disord. 2016;16:61. doi: 10.1186/s12872-016-0235-1.Westenbrink B.D., Alings M., Granger C.B. et al. Anemia is associated with bleeding and mortality, but not stroke, in patients with atrial fibrillation: Insights from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. Am Heart J. 2017;185:140-149. doi: 10.1016/j.ahj.2016.12.008.Westenbrink B.D., Alings M., Granger C.B. et al. Anemia is associated with bleeding and mortality, but not stroke, in patients with atrial fibrillation: Insights from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. Am Heart J. 2017;185:140-149. doi: 10.1016/j.ahj.2016.12.008.Michniewicz E., Mlodawska E., Lopatowska P. et al. Patients with atrial fibrillation and coronary artery disease -Double trouble. Adv Med Sci. 2018;63(1):30-35. doi: 10.1016/j.advms.2017.06.005.Michniewicz E., Mlodawska E., Lopatowska P. et al. Patients with atrial fibrillation and coronary artery disease -Double trouble. Adv Med Sci. 2018;63(1):30-35. doi: 10.1016/j.advms.2017.06.005.Hohnloser S.H., Hijazi Z., Thomas L. et al. Efficacy of apixaban when compared with warfarin in relation to renal function in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J. 2012;33(22):2821-2830. doi: 10.1093/eurheartj/ehs274.Hohnloser S.H., Hijazi Z., Thomas L. et al. Efficacy of apixaban when compared with warfarin in relation to renal function in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J. 2012;33(22):2821-2830. doi: 10.1093/eurheartj/ehs274.Hohnloser S.H., Hijazi Z., Thomas L. et al. Efficacy of apixaban when compared with warfarin in relation to renal function in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J. 2012;33(22):2821-2830. doi: 10.1093/eurheartj/ehs274.Hohnloser S.H., Hijazi Z., Thomas L. et al. Efficacy of apixaban when compared with warfarin in relation to renal function in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J. 2012;33(22):2821-2830. doi: 10.1093/eurheartj/ehs274.Lopes R.D., Alexander J.H., Al-Khatib S.M. et al. Apixaban for reduction in stroke and other ThromboemboLic events in atrial fibrillation (ARISTOTLE) trial: design and rationale. Am Heart J. 2010;159(3):331-339. doi: 10.1016/j.ahj.2009.07.035.Lopes R.D., Alexander J.H., Al-Khatib S.M. et al. Apixaban for reduction in stroke and other ThromboemboLic events in atrial fibrillation (ARISTOTLE) trial: design and rationale. Am Heart J. 2010;159(3):331-339. doi: 10.1016/j.ahj.2009.07.035.Lindner S.M., Fordyce C.B., Hellkamp A.S. et al. Treatment Consistency Across Levels of Baseline Renal Function With Rivaroxaban or Warfarin: A 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) Analysis. Circulation. 2017;135(10):1001-1003. doi: 10.1161/CIRCULATIONAHA. 116.024666.Lindner S.M., Fordyce C.B., Hellkamp A.S. et al. Treatment Consistency Across Levels of Baseline Renal Function With Rivaroxaban or Warfarin: A 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) Analysis. Circulation. 2017;135(10):1001-1003. doi: 10.1161/CIRCULATIONAHA. 116.024666.Hanon O., Vidal J.S., Pisica-Donose G. et al. Bleeding risk with rivaroxaban compared with vitamin K antagonists in patients aged 80 years or older with atrial fibrillation. Heart. 2021 Sep;107(17):1376-1382. doi: 10.1136/heartjnl-2020-317923. Epub 2020 Dec 1. PMID: 33262185.Hanon O., Vidal J.S., Pisica-Donose G. et al. Bleeding risk with rivaroxaban compared with vitamin K antagonists in patients aged 80 years or older with atrial fibrillation. Heart. 2021 Sep;107(17):1376-1382. doi: 10.1136/heartjnl-2020-317923. Epub 2020 Dec 1. PMID: 33262185.Agnelli G., Becattini C., Meyer G. et al., on behalf of the Caravaggio Investigators. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med 2020; Mar 29:[Epub ahead of print].Agnelli G., Becattini C., Meyer G. et al., on behalf of the Caravaggio Investigators. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med 2020; Mar 29:[Epub ahead of print].Gibson C.M., Mehran R., Bode C. et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med. 2016;375(25):2423-2434. doi: 10.1056/NEJMoa1611594.Gibson C.M., Mehran R., Bode C. et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med. 2016;375(25):2423-2434. doi: 10.1056/NEJMoa1611594.

The authors declare that there are no conflicts of interest present.