Go A S, Hylek E M, Borowsky L H, Phillips K A, Selby J V, Singer D E
Kaiser Permanente Medical Care Program (Northern California), Oakland 94611-5714, USA.
Ann Intern Med. 1999 Dec 21;131(12):927-34. doi: 10.7326/0003-4819-131-12-199912210-00004.
Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied.
To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation.
Cross-sectional study.
Large health maintenance organization.
13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997.
Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation.
Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]).
In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates.
华法林可显著降低非瓣膜性心房颤动患者发生缺血性卒中的风险，但在非卧床心房颤动患者中使用华法林的情况尚未得到广泛研究。
评估非卧床非瓣膜性心房颤动患者使用华法林的比例及其预测因素。
横断面研究。
大型健康维护组织。
1996年7月1日至1997年12月31日期间确诊为非卧床非瓣膜性心房颤动且已知华法林使用情况的13428例患者。
利用自动药房、实验室及临床管理数据库中的数据，确定在确诊心房颤动前后3个月内使用华法林的患病率及决定因素。
在11082例无已知禁忌证的非瓣膜性心房颤动患者中，55%使用了华法林。年龄小于55岁的患者（44.3%）及85岁及以上的患者（35.4%）使用华法林的比例显著较低。在有一个或多个卒中危险因素且无禁忌证的患者中，仅59.3%使用了华法林。在一组接受华法林治疗的“理想”候选患者（65至74岁、无禁忌证且既往有卒中、高血压或二者兼具）中，62.1%有使用华法林的证据。在我们的整个队列中，使用华法林的最强预测因素为既往卒中（校正比值比，2.55[95%CI，2.23至2.92]）、心力衰竭（比值比，1.63[CI，1.51至1.77]）、既往颅内出血（比值比，0.33[CI，0.21至0.52]）、85岁及以上（比值比，0.35[CI，0.31至0.40]）及既往胃肠道出血（比值比，0.47[CI，0.40至0.57]）。
在一个大型的、当代的、在健康维护组织接受治疗的非卧床心房颤动患者队列中，华法林的使用比例显著高于其他报道的研究。尽管无法阐明医生未开具华法林的原因，但许多明显符合条件的心房颤动患者且至少有一项额外的卒中危险因素，尤其是高血压患者，未接受抗凝治疗。需要采取干预措施以增加合适候选者中为预防卒中而使用华法林的比例。
