Man-Son-Hing Malcolm, Laupacis Andreas
Clinical Epidemiology Program, Ottawa Health Research Institute, Geriatric Assessment Unit, Ottawa Hospital, and Division of Geriatric Medicine, University of Ottawa, Ontario, Canada.
Arch Intern Med. 2003 Jul 14;163(13):1580-6. doi: 10.1001/archinte.163.13.1580.
Many studies have documented the underuse of anticoagulant (ie, warfarin sodium) therapy as stroke prophylaxis in older persons with atrial fibrillation. Failure to prescribe anticoagulant agents to these patients is often due to physicians' perceiving the risk of major bleeding as unacceptably high because of the presence of such clinical risk factors as hypertension, falls, a history of gastrointestinal tract bleeding, and lack of assurance about compliance.
To critically appraise whether the presence of additional clinical factors that increase the risk of bleeding affects the chance of anticoagulant-related hemorrhage, and to develop an approach to the use of anticoagulant agents in older patients with atrial fibrillation who have any of these factors.
Systematic MEDLINE literature search from January 1966 to March 2002.
Many of the factors that are purported to be barriers to anticoagulant therapy in older persons with atrial fibrillation probably should not influence the choice of stroke prophylaxis in these patients. These include previous episodes of upper gastrointestinal tract bleeding, predisposition to falling, and old age in itself. For some other factors, such as alcoholism, participation in activities that predispose to trauma, the presence of a bleeding diathesis or thrombocytopenia, and noncompliance with monitoring, there is little or conflicting evidence about their effect on anticoagulant-related bleeding. However, they should be considered in the clinical decision-making process.
For many older patients with atrial fibrillation, physicians' fears of the risk of bleeding in association with anticoagulant therapy are often exaggerated and unfounded. Therefore, the salient issue in selecting older patients with atrial fibrillation for anticoagulation is accurately estimating their stroke risk, with bleeding risk during anticoagulation being a lesser issue, relevant to only a few patients.
许多研究记录了在老年房颤患者中，抗凝治疗（即华法林钠）作为预防中风的措施未得到充分应用的情况。未给这些患者开具抗凝药物往往是因为医生认为由于存在高血压、跌倒、胃肠道出血史等临床风险因素，以及对依从性缺乏保障，大出血风险高得令人无法接受。
批判性地评估增加出血风险的其他临床因素的存在是否会影响抗凝相关出血的几率，并制定一种方法，用于在患有这些因素中任何一种的老年房颤患者中使用抗凝药物。
对1966年1月至2002年3月期间的MEDLINE文献进行系统检索。
许多据称是老年房颤患者抗凝治疗障碍的因素，可能不应影响这些患者预防中风的选择。这些因素包括既往上消化道出血发作、易跌倒倾向以及高龄本身。对于其他一些因素，如酗酒、参与易致创伤的活动、存在出血素质或血小板减少症以及不遵守监测，关于它们对抗凝相关出血的影响几乎没有证据或证据相互矛盾。然而，在临床决策过程中应考虑这些因素。
对于许多老年房颤患者，医生对抗凝治疗相关出血风险的担忧往往被夸大且毫无根据。因此，在选择老年房颤患者进行抗凝治疗时，突出问题是准确评估他们的中风风险，而抗凝期间的出血风险是一个次要问题，仅与少数患者相关。
