BioMedCom Consultants Inc., Montréal, QC, Canada.
Am J Med. 2010 Jul;123(7):638-645.e4. doi: 10.1016/j.amjmed.2009.11.025.
Atrial fibrillation is associated with substantial mortality and morbidity from stroke and thromboembolism. Despite an efficacious oral anticoagulation therapy (warfarin), atrial fibrillation patients at high risk for stroke are often under-treated. This systematic review compares current treatment practices for stroke prevention in atrial fibrillation with published guidelines.
Literature searches (1997-2008) identified 98 studies concerning current treatment practices for stroke prevention in atrial fibrillation. The percentage of patients eligible for oral anticoagulation due to elevated stroke risk was compared with the percentage treated. Under-treatment was defined as treatment of <70% of high-risk patients.
Of 54 studies that reported stroke risk levels and the percentage of patients treated, most showed underuse of oral anticoagulants for high-risk patients. From 29 studies of patients with prior stroke/transient ischemic attack who should all receive oral anticoagulation according to published guidelines, 25 studies reported under-treatment, with 21 of 29 studies reporting oral anticoagulation treatment levels below 60% (range 19%-81.3%). Subjects with a CHADS(2) (congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score >or=2 also were suboptimally treated, with 7 of 9 studies reporting treatment levels below 70% (range 39%-92.3%). Studies (21 of 54) using other stroke risk stratification schemes differ in the criteria they use to designate patients as "high risk," such that direct comparison is not possible.
This systematic review demonstrates the underuse of oral anticoagulation therapy for real-world atrial fibrillation patients with an elevated risk of stroke, highlighting the need for improved therapies for stroke prevention in atrial fibrillation.
房颤与中风和血栓栓塞引起的大量死亡率和发病率有关。尽管有有效的口服抗凝治疗（华法林），但房颤患者中风高危人群往往治疗不足。本系统评价比较了目前房颤患者中风预防的治疗实践与已发表的指南。
文献检索（1997-2008 年）确定了 98 项关于房颤中风预防的当前治疗实践的研究。因中风风险升高而有资格接受口服抗凝治疗的患者比例与接受治疗的患者比例进行了比较。治疗不足定义为治疗高危患者的比例<70%。
在报告中风风险水平和接受治疗的患者比例的 54 项研究中，大多数研究表明，高危患者口服抗凝剂的使用率较低。在 29 项有既往中风/短暂性脑缺血发作的患者研究中，所有患者都应根据已发表的指南接受口服抗凝治疗，其中 25 项研究报告治疗不足，29 项研究中有 21 项报告口服抗凝治疗水平低于 60%（范围 19%-81.3%）。CHADS2（充血性心力衰竭、高血压、年龄>75 岁、糖尿病和既往中风或短暂性脑缺血发作）评分>或=2 的患者也治疗不足，9 项研究中有 7 项报告治疗水平低于 70%（范围 39%-92.3%）。使用其他中风风险分层方案的研究（54 项中的 21 项）在用于指定患者为“高危”的标准上存在差异，因此无法直接比较。
本系统评价表明，实际房颤患者中风风险升高的患者口服抗凝治疗使用率较低，突出了需要改善房颤中风预防的治疗方法。
