Informagenics, LLC, Worthington, OH 43085, USA.
Drugs Aging. 2013 Jun;30(6):417-28. doi: 10.1007/s40266-013-0067-y.
The aims of the study were to evaluate usage rates of warfarin in stroke prophylaxis and the association with assessed stages of stroke and bleeding risk in long-term care (LTC) residents with atrial fibrillation (AFib).
A cross-sectional analysis of two LTC databases (the National Nursing Home Survey [NNHS] 2004 and an integrated LTC database: AnalytiCare) was conducted. The study involved LTC facilities across the USA (NNHS) and within 19 states (AnalytiCare). It included LTC residents diagnosed with AFib (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] diagnostic code 427.3X). Consensus guideline algorithms were used to classify residents by stroke risk categories: low (none or 1+ weak stroke risk factors), moderate (1 moderate), high (2+ moderate or 1+ high). Residents were also classified by number of risk factors for bleeding (0-1, 2, 3, 4+). Current use of warfarin was assessed. A logistic regression model predicted odds of warfarin use associated with the stroke and bleeding risk categories.
The NNHS and AnalytiCare databases had 1,454 and 3,757 residents with AFib, respectively. In all, 34 % and 45 % of residents with AFib in each respective database were receiving warfarin. Only 36 % and 45 % of high-stroke-risk residents were receiving warfarin, respectively. In the logistic regression model for the NNHS data, when compared with those residents having none or 1+ weak stroke risk and 0-1 bleeding risk factors, the odds of receiving warfarin increased with stroke risk (odds ratio [OR] = 1.93, p = 0.118 [1 moderate risk factor]; OR = 3.19, p = 0.005 [2+ moderate risk factors]; and OR = 8.18, p ≤ 0.001 [1+ high risk factors]) and decreased with bleeding risk (OR = 0.83, p = 0.366 [2 risk factors]; OR = 0.47, p ≤ 0.001 [3 risk factors]; OR = 0.17, p ≤ 0.001 [4+ risk factors]). A similar directional but more constrained trend was noted for the AnalytiCare data: only 3 and 4+ bleeding risk factors were significant.
The results from two LTC databases suggest that residents with AFib have a high risk of stroke. Warfarin use increased with greater stroke risk and declined with greater bleeding risk; however, only half of those classified as appropriate warfarin candidates were receiving guideline-recommended anticoagulant prophylaxis.
本研究旨在评估华法林在预防中风中的使用情况，并探讨其与长期护理（LTC）机构中伴有心房颤动（AFib）的患者中风严重程度和出血风险评估等级之间的相关性。
对两个 LTC 数据库（国家护理院调查[NNHS]2004 年和集成 LTC 数据库：AnalytiCare）进行了横断面分析。该研究涵盖了美国（NNHS）和 19 个州（AnalytiCare）的 LTC 机构。研究对象为诊断为 AFib 的 LTC 居民（国际疾病分类，第九版，临床修订版[ICD-9-CM]诊断代码 427.3X）。采用共识指南算法对中风风险类别进行分类：低危（无或 1 个以上弱中风危险因素）、中危（1 个中度）、高危（2 个中度或 1 个以上高危）。还根据出血风险因素的数量（0-1、2、3、4+）对居民进行分类。评估了华法林的当前使用情况。使用逻辑回归模型预测与中风和出血风险类别相关的华法林使用概率。
NNHS 和 AnalytiCare 数据库分别有 1454 名和 3757 名患有 AFib 的居民。在每个数据库中，分别有 34%和 45%的 AFib 患者正在服用华法林。仅有 36%和 45%的高危中风患者正在服用华法林。在 NNHS 数据的逻辑回归模型中，与仅有 1 个或 1 个以上弱中风危险因素和 0-1 个出血危险因素的患者相比，随着中风风险的增加，服用华法林的概率也增加（比值比[OR]为 1.93，p = 0.118[1 个中度危险因素]；OR = 3.19，p = 0.005[2 个中度危险因素]；OR = 8.18，p ≤ 0.001[1 个以上高危因素]），而随着出血风险的增加则降低（OR = 0.83，p = 0.366[2 个危险因素]；OR = 0.47，p ≤ 0.001[3 个危险因素]；OR = 0.17，p ≤ 0.001[4 个以上危险因素]）。AnalytiCare 数据中也观察到类似的方向但更受限制的趋势：只有 3 个和 4 个以上的出血危险因素具有显著意义。
来自两个 LTC 数据库的结果表明，AFib 患者中风风险很高。华法林的使用随着中风风险的增加而增加，随着出血风险的增加而减少；然而，只有一半被归类为华法林合适候选者的患者正在接受指南推荐的抗凝预防治疗。
