心房颤动伴慢性肾脏病的卒中与出血。

Stroke and bleeding in atrial fibrillation with chronic kidney disease.

机构信息

Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark.

出版信息

N Engl J Med. 2012 Aug 16;367(7):625-35. doi: 10.1056/NEJMoa1105594.

DOI:10.1056/NEJMoa1105594

PMID:22894575

Abstract

BACKGROUND

Both atrial fibrillation and chronic kidney disease increase the risk of stroke and systemic thromboembolism. However, these risks, and the effects of antithrombotic treatment, have not been thoroughly investigated in patients with both conditions.

METHODS

Using Danish national registries, we identified all patients discharged from the hospital with a diagnosis of nonvalvular atrial fibrillation between 1997 and 2008. The risk of stroke or systemic thromboembolism and bleeding associated with non-end-stage chronic kidney disease and with end-stage chronic kidney disease (i.e., disease requiring renal-replacement therapy) was estimated with the use of time-dependent Cox regression analyses. In addition, the effects of treatment with warfarin, aspirin, or both in patients with chronic kidney disease were compared with the effects in patients with no renal disease.

RESULTS

Of 132,372 patients included in the analysis, 3587 (2.7%) had non-end-stage chronic kidney disease and 901 (0.7%) required renal-replacement therapy at the time of inclusion. As compared with patients who did not have renal disease, patients with non-end-stage chronic kidney disease had an increased risk of stroke or systemic thromboembolism (hazard ratio, 1.49; 95% confidence interval [CI], 1.38 to 1.59; P<0.001), as did those requiring renal-replacement therapy (hazard ratio, 1.83; 95% CI, 1.57 to 2.14; P<0.001); this risk was significantly decreased for both groups of patients with warfarin but not with aspirin. The risk of bleeding was also increased among patients who had non-end-stage chronic kidney disease or required renal-replacement therapy and was further increased with warfarin, aspirin, or both.

CONCLUSIONS

Chronic kidney disease was associated with an increased risk of stroke or systemic thromboembolism and bleeding among patients with atrial fibrillation. Warfarin treatment was associated with a decreased risk of stroke or systemic thromboembolism among patients with chronic kidney disease, whereas warfarin and aspirin were associated with an increased risk of bleeding. (Funded by the Lundbeck Foundation.).

摘要

背景

心房颤动和慢性肾脏病都会增加中风和全身性血栓栓塞的风险。然而，这些风险以及抗血栓治疗的效果，在同时患有这两种疾病的患者中尚未得到充分研究。

方法

我们利用丹麦全国性登记处的数据，确定了在 1997 年至 2008 年期间因非瓣膜性心房颤动住院的所有患者。使用时间依赖性 Cox 回归分析来评估非终末期慢性肾脏病和终末期慢性肾脏病（即需要肾脏替代治疗的疾病）相关的中风或全身性血栓栓塞以及出血风险。此外，还比较了慢性肾脏病患者使用华法林、阿司匹林或两者联合治疗的效果与无肾脏疾病患者的效果。

结果

在纳入分析的 132372 名患者中，有 3587 名（2.7%）患有非终末期慢性肾脏病，901 名（0.7%）在纳入时需要肾脏替代治疗。与无肾脏疾病的患者相比，患有非终末期慢性肾脏病的患者中风或全身性血栓栓塞的风险增加（风险比，1.49；95%置信区间[CI]，1.38 至 1.59；P<0.001），需要肾脏替代治疗的患者风险更高（风险比，1.83；95%CI，1.57 至 2.14；P<0.001）；华法林治疗可显著降低这两组患者的风险，但阿司匹林治疗则不然。患有非终末期慢性肾脏病或需要肾脏替代治疗的患者出血风险也增加，且华法林、阿司匹林或两者联合治疗会进一步增加出血风险。