Segal J B, McNamara R L, Miller M R, Kim N, Goodman S N, Powe N R, Robinson K A, Bass E B
Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
J Gen Intern Med. 2000 Jan;15(1):56-67. doi: 10.1046/j.1525-1497.2000.04329.x.
Appropriate use of drugs to prevent thromboembolism in patients with atrial fibrillation (AF) involves comparing the patient's risk of stroke and risk of hemorrhage. This review summarizes the evidence regarding the efficacy of these medications.
We conducted a meta-analysis of randomized controlled trials of drugs used to prevent thromboembolism in adults with nonpostoperative AF. Articles were identified through the Cochrane Collaboration's CENTRAL database and MEDLINE until May 1998.
Eleven articles met criteria for inclusion in this review. Warfarin was more efficacious than placebo for primary stroke prevention (aggregate odds ratio [OR] of stroke = 0.30, 95% confidence interval [CI] 0.19, 0.48), with moderate evidence of more major bleeding (OR 1.90; 95% CI 0.89, 4.04). Aspirin was inconclusively more efficacious than placebo for stroke prevention (OR 0.56, 95% CI 0.19, 1.65), with inconclusive evidence regarding more major bleeds (OR 0.81, 95% CI 0.37, 1.77). For primary prevention, assuming a baseline risk of 45 strokes per 1,000 patient-years, warfarin could prevent 30 strokes at the expense of only 6 additional major bleeds. Aspirin could prevent 17 strokes, without increasing major hemorrhage. In direct comparison, there was evidence suggesting fewer strokes among patients on warfarin than among patients on aspirin (aggregate OR 0.64, 95% CI 0.43, 0.96), with only suggestive evidence for more major hemorrhage (OR 1.60, 95% CI 0.77,3.35). However, in younger patients, with a mean age of 65 years, the absolute reduction in stroke rate with warfarin compared with aspirin was low (5.5 per 1,000 person-years) compared with an older group (15 per 1,000 person-years).
In general, the evidence strongly supports warfarin for patients with AF at average or greater risk of stroke. Aspirin may prove to be useful in subgroups with a low risk of stroke, although this is not definitively supported by the evidence.
心房颤动（AF）患者预防血栓栓塞的药物合理应用涉及比较患者的卒中风险和出血风险。本综述总结了这些药物疗效的相关证据。
我们对用于非术后AF成年患者预防血栓栓塞的药物随机对照试验进行了荟萃分析。通过Cochrane协作网的CENTRAL数据库和MEDLINE检索截至1998年5月的文章。
11篇文章符合本综述的纳入标准。华法林在预防初次卒中方面比安慰剂更有效（卒中的综合比值比[OR]=0.30，95%置信区间[CI]0.19，0.48），有中等证据表明大出血更多（OR 1.90；95%CI 0.89，4.04）。阿司匹林在预防卒中方面比安慰剂更有效的证据不明确（OR 0.56，95%CI 0.19，1.65），关于大出血更多的证据也不明确（OR 0.81，95%CI 0.37，1.77）。对于一级预防，假设每1000患者年的基线卒中风险为45次，华法林可以预防30次卒中，代价是仅增加6次大出血。阿司匹林可以预防17次卒中，且不增加大出血。直接比较显示，有证据表明服用华法林的患者卒中比服用阿司匹林的患者少（综合OR 0.64，95%CI 0.43，0.96），只有提示性证据表明大出血更多（OR 1.60，95%CI 0.77，3.35）。然而，在平均年龄为65岁的较年轻患者中，与年龄较大组（每1000人年15次）相比，华法林与阿司匹林相比卒中率的绝对降低幅度较小（每1000人年5.5次）。
总体而言，证据强烈支持华法林用于卒中风险平均或更高的AF患者。阿司匹林可能对卒中风险较低的亚组有用，尽管证据并未明确支持这一点。
