Gage Brian F, Birman-Deych Elena, Kerzner Roger, Radford Martha J, Nilasena David S, Rich Michael W
Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA.
Am J Med. 2005 Jun;118(6):612-7. doi: 10.1016/j.amjmed.2005.02.022.
Patients at high risk for falls are presumed to be at increased risk for intracranial hemorrhage, and high risk for falls is cited as a contraindication to antithrombotic therapy. Data substantiating this concern are lacking.
Quality improvement organizations identified 1245 Medicare beneficiaries who were documented in the medical record to be at high risk of falls and 18261 other patients with atrial fibrillation. The patients were elderly (mean 80 years), and 48% were prescribed warfarin at hospital discharge. The primary endpoint was subsequent hospitalization for an intracranial hemorrhage, based on ICD-9 codes.
Rates (95% confidence interval [CI]) of intracranial hemorrhage per 100 patient-years were 2.8 (1.9-4.1) in patients at high risk for falls and 1.1 (1.0-1.3) in other patients. Rates (95% CI) of traumatic intracranial hemorrhage were 2.0 (1.3-3.1) in patients at high risk for falls and 0.34 (0.27-0.45) in other patients. Hazard ratios (95% CI) of other independent risk factors for intracranial hemorrhage were 1.4 (1.0-3.1) for neuropsychiatric disease, 2.1 (1.6-2.7) for prior stroke, and 1.9 (1.4-2.4) for prior major bleeding. Warfarin prescription was associated with intracranial hemorrhage mortality but not with intracranial hemorrhage occurrence. Ischemic stroke rates per 100 patient-years were 13.7 in patients at high risk for falls and 6.9 in other patients. Warfarin prescription in patients prone to fall who had atrial fibrillation and multiple additional stroke risk factors appeared to protect against a composite endpoint of stroke, intracranial hemorrhage, myocardial infarction, and death.
Patients at high risk for falls with atrial fibrillation are at substantially increased risk of intracranial hemorrhage, especially traumatic intracranial hemorrhage. However, because of their high stroke rate, they appear to benefit from anticoagulant therapy if they have multiple stroke risk factors.
跌倒高危患者被认为颅内出血风险增加，且跌倒高危被视为抗栓治疗的禁忌证。但缺乏证实这一担忧的数据。
质量改进组织识别出1245名在病历中有跌倒高危记录的医疗保险受益人以及18261名其他房颤患者。这些患者均为老年人（平均80岁），48%在出院时接受华法林治疗。主要终点是基于ICD - 9编码的后续因颅内出血住院治疗情况。
每100患者 - 年的颅内出血发生率（95%置信区间[CI]）在跌倒高危患者中为2.8（1.9 - 4.1），在其他患者中为1.1（1.0 - 1.3）。创伤性颅内出血发生率（95%CI）在跌倒高危患者中为2.0（1.3 - 3.1），在其他患者中为0.34（0.27 - 0.45）。颅内出血其他独立危险因素的风险比（95%CI），神经精神疾病为1.4（1.0 - 3.1），既往中风为2.1（1.6 - 2.7），既往重大出血为1.9（1.4 - 2.4）。华法林处方与颅内出血死亡率相关，但与颅内出血发生无关。每100患者 - 年的缺血性中风发生率在跌倒高危患者中为13.7，在其他患者中为6.9。对于有房颤且有多种额外中风危险因素的易跌倒患者，华法林处方似乎可预防中风、颅内出血、心肌梗死和死亡的复合终点事件。
有房颤的跌倒高危患者颅内出血风险大幅增加，尤其是创伤性颅内出血。然而，由于其高中风发生率，如果他们有多种中风危险因素，似乎可从抗凝治疗中获益。
