Department of Cardiology, Hospital General Universitario de Alicante, Alicante, Spain.
Circ Cardiovasc Interv. 2012 Aug 1;5(4):459-66. doi: 10.1161/CIRCINTERVENTIONS.112.968792. Epub 2012 Jul 10.
Recent European guidelines for the management of atrial fibrillation recommend oral anticoagulation (OAC) in patients with CHA(2)DS(2)-VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes, history of previous stroke, vascular disease, age 65-74 years, and sex category [female]) ≥1. The HAS-BLED score (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly [>65 years], Drugs/alcohol concomitantly) has been suggested to assess bleeding risk in patients with atrial fibrillation (score ≥3 indicates high risk of bleeding). Despite the guidelines, this approach has never been tested in a cohort of patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation.
We studied 590 consecutive patients with atrial fibrillation undergoing percutaneous coronary intervention/stenting and CHA(2)DS(2)-VASC score >1 (ie, OAC recommended). We compared patients with low-intermediate bleeding risk (HAS-BLED 0-2) and high risk (HAS-BLED ≥3), the relation between CHA(2)DS(2)-VASC and HAS-BLED, and the benefit and risks of the use of OAC in patients with high bleeding risk. The development of any bleeding episode, thromboembolism, mortality, cardiac events, and the composite major adverse cardiac events (ie, death, acute myocardial infarction, and/or target lesion revascularization) end point was recorded as well as the composite major adverse events (ie, major adverse cardiac events, major bleeding, or thromboembolism) end point at 1-year follow-up. Of the study cohort, 420 (71%) had a HAS-BLED score ≥3, and patients who were on OAC at discharge had lower mortality rate (9.3% versus 20.1%; P<0.01) and major adverse cardiac events (13.0% versus 26.4%; P<0.01) but with a similar major adverse event (20.5% versus 27.6%; P=0.11) and higher major bleeding rate (11.8% versus 4.0%; P<0.01). In a Cox multivariable analysis in patients with HAS-BLED ≥3, predictors of increased death were chronic renal failure and heart failure (both P<0.05), whereas OAC at discharge was associated with a reduced death rate (P<0.01). Predictors of major bleeding were chronic renal failure and the use of drug-eluting stents (both P<0.05).
Most patients with atrial fibrillation undergoing percutaneous coronary intervention/stenting have a high risk for major bleeding (HAS-BLED score ≥3). Even in these patients, OAC improves prognosis in these patients (reduced mortality and major adverse cardiac events) with an increase in major bleeding.
最近的欧洲房颤管理指南建议 CHA （ 2 ） DS （ 2 ） -VASc 评分（充血性心力衰竭、高血压、年龄≥ 75 岁、糖尿病、既往卒中史、血管疾病、年龄 65-74 岁和性别[女性]）≥ 1 的房颤患者进行口服抗凝治疗（ OAC ）。 HAS-BLED 评分（高血压、异常肾功能/肝功能、卒中、出血史或倾向、不稳定的国际标准化比值、老年[> 65 岁]、同时使用药物/酒精）已被建议用于评估房颤患者的出血风险（评分≥ 3 表示出血风险高）。尽管有指南，但这种方法从未在接受经皮冠状动脉介入治疗和支架植入的房颤患者队列中进行过测试。
我们研究了 590 例接受经皮冠状动脉介入治疗/支架植入且 CHA （ 2 ） DS （ 2 ） -VASC 评分> 1 （即推荐使用 OAC ）的房颤连续患者。我们比较了低-中出血风险（ HAS-BLED0-2 ）和高风险（ HAS-BLED ≥ 3 ）患者、 CHA （ 2 ） DS （ 2 ） -VASC 和 HAS-BLED 之间的关系，以及高出血风险患者使用 OAC 的获益和风险。记录了任何出血事件、血栓栓塞、死亡率、心脏事件和主要不良心脏事件的复合终点（即死亡、急性心肌梗死和/或靶病变血运重建）以及 1 年随访时的主要不良复合事件（即主要不良心脏事件、大出血或血栓栓塞）终点。在研究队列中， 420 例（ 71% ）患者 HAS-BLED 评分≥ 3 ，出院时服用 OAC 的患者死亡率（ 9.3% 对 20.1% ； P < 0.01 ）和主要不良心脏事件（ 13.0% 对 26.4% ； P < 0.01 ）较低，但主要不良事件（ 20.5% 对 27.6% ； P = 0.11 ）相似，大出血发生率较高（ 11.8% 对 4.0% ； P < 0.01 ）。在 HAS-BLED ≥ 3 的患者中， Cox 多变量分析的结果表明，慢性肾功能衰竭和心力衰竭是死亡增加的预测因素（均 P < 0.05 ），而出院时使用 OAC 与死亡率降低相关（ P < 0.01 ）。主要出血的预测因素是慢性肾功能衰竭和使用药物洗脱支架（均 P < 0.05 ）。
大多数接受经皮冠状动脉介入治疗/支架植入的房颤患者有发生大出血（ HAS-BLED 评分≥ 3 ）的高风险。即使在这些患者中， OAC 也改善了这些患者的预后（降低死亡率和主要不良心脏事件），同时增加了大出血的风险。
