Rothberg Michael B, Celestin Carmel, Fiore Louis D, Lawler Elizabeth, Cook James R
Division of General Medicine and Geriatrics, Baystate Medical Center, Springfield, Massachusetts 01199, USA.
Ann Intern Med. 2005 Aug 16;143(4):241-50. doi: 10.7326/0003-4819-143-4-200508160-00005.
After the acute coronary syndrome, adding warfarin to standard aspirin therapy decreases myocardial infarction and stroke but increases major bleeding.
To quantify the risks and benefits of warfarin therapy after the acute coronary syndrome.
MEDLINE from 1990 to October 2004. Additional data were obtained from study authors. Clinical risk factors were used to classify hypothetical patients into cardiovascular and bleeding risk groups on the basis of published data.
Randomized trials comparing intensive warfarin therapy (international normalized ratio > 2.0) plus aspirin with aspirin alone after the acute coronary syndrome.
Two reviewers independently selected studies and extracted data on study design; quality; and clinical outcomes, including myocardial infarction, stroke, revascularization, death, and major and minor bleeding. Rate ratios for outcomes were calculated and pooled by using the method of DerSimonian and Laird.
Ten trials involving a total of 5938 patients (11,334 patient-years) met the study criteria. Compared with aspirin alone, warfarin plus aspirin was associated with a decrease in the annual rate of myocardial infarction (0.022 vs. 0.041; rate ratio, 0.56 [95% CI, 0.46 to 0.69]), ischemic stroke (0.004 vs. 0.008; rate ratio, 0.46 [CI, 0.27 to 0.77]), and revascularization (0.115 vs. 0.135; rate ratio, 0.80 [CI, 0.67 to 0.95]). Warfarin was associated with an increase in major bleeding (0.015 vs. 0.006; rate ratio, 2.5 [CI, 1.7 to 3.7]). Mortality did not differ.
Two large studies provided most of the data. Studies did not include coronary stenting, and results should not be applied to patients with stents. Relative risk reductions may not be consistent across risk groups.
For patients with the acute coronary syndrome who are at low or intermediate risk for bleeding, the cardiovascular benefits of warfarin outweigh the bleeding risks.
急性冠状动脉综合征后，在标准阿司匹林治疗基础上加用华法林可降低心肌梗死和中风发生率，但会增加严重出血风险。
量化急性冠状动脉综合征后华法林治疗的风险与获益。
1990年至2004年10月的MEDLINE数据库。其他数据从研究作者处获取。根据已发表数据，使用临床危险因素将假设患者分为心血管疾病风险组和出血风险组。
比较急性冠状动脉综合征后强化华法林治疗（国际标准化比值>2.0）加阿司匹林与单用阿司匹林的随机试验。
两名评价者独立选择研究并提取有关研究设计、质量以及临床结局的数据，包括心肌梗死、中风、血管重建、死亡以及严重和轻微出血。采用DerSimonian和Laird方法计算并汇总结局的率比。
10项试验共纳入5938例患者（11334患者年），符合研究标准。与单用阿司匹林相比，华法林加阿司匹林可降低心肌梗死年发生率（0.022对0.041；率比，0.56 [95%CI，0.46至0.69]）、缺血性中风发生率（0.004对0.008；率比，0.46 [CI，0.27至0.77]）以及血管重建率（0.115对0.135；率比，0.80 [CI，0.67至0.95]）。华法林会增加严重出血发生率（0.015对0.006；率比，2.5 [CI，1.7至3.7]）。死亡率无差异。
两项大型研究提供了大部分数据。研究未纳入冠状动脉支架置入术，结果不适用于有支架的患者。不同风险组的相对风险降低可能不一致。
对于出血风险低或中等的急性冠状动脉综合征患者，华法林的心血管获益大于出血风险。
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