识别滥用药物患者的抗凝风险。
Identifying the risks of anticoagulation in patients with substance abuse.
机构信息
Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, 72 East Concord Street, Evans 124, Boston, MA, 02118, USA,
出版信息
J Gen Intern Med. 2013 Oct;28(10):1333-9. doi: 10.1007/s11606-013-2453-x. Epub 2013 Apr 26.
BACKGROUND
Warfarin is effective in preventing thromboembolic events, but concerns exist regarding its use in patients with substance abuse.
OBJECTIVE
Identify which patients with substance abuse who receive warfarin are at risk for poor outcomes.
DESIGN
Retrospective cohort study. Diagnostic codes, lab values, and other factors were examined to identify risk of adverse outcomes.
PATIENTS
Veterans AffaiRs Study to Improve Anticoagulation (VARIA) database of 103,897 patients receiving warfarin across 100 sites.
MAIN MEASURES
Outcomes included percent time in therapeutic range (TTR), a measure of anticoagulation control, and major hemorrhagic events by ICD-9 codes.
RESULTS
Nonusers had a higher mean TTR (62 %) than those abusing alcohol (53 %), drugs (50 %), or both (44 %, p < 0.001). Among alcohol abusers, an increasing ratio of the serum hepatic transaminases aspartate aminotransferase/alanine aminotransferase (AST:ALT) correlated with inferior anticoagulation control; normal AST:ALT ≤ 1.5 predicted relatively modest decline in TTR (54 %, p < 0.001), while elevated ratios (AST:ALT 1.50-2.0 and > 2.0) predicted progressively poorer anticoagulation control (49 % and 44 %, p < 0.001 compared to nonusers). Age-adjusted hazard ratio for major hemorrhage was 1.93 in drug and 1.37 in alcohol abuse (p < 0.001 compared to nonusers), and remained significant after also controlling for anticoagulation control and other bleeding risk factors (1.69 p < 0.001 and 1.22 p = 0.003). Among alcohol abusers, elevated AST:ALT >2.0 corresponded to more than three times the hemorrhages (HR 3.02, p < 0.001 compared to nonusers), while a normal ratio AST:ALT ≤ 1.5 predicted a rate similar to nonusers (HR 1.19, p < 0.05).
CONCLUSIONS
Anticoagulation control is particularly poor in patients with substance abuse. Major hemorrhages are more common in both alcohol and drug users. Among alcohol abusers, the ratio of AST/ALT holds promise for identifying those at highest risk for adverse events.
背景
华法林在预防血栓栓塞事件方面有效，但人们对其在滥用物质的患者中的应用存在担忧。
目的
确定接受华法林治疗的滥用物质患者中哪些患者有发生不良结局的风险。
设计
回顾性队列研究。通过诊断代码、实验室值和其他因素来确定不良结局的风险。
患者
退伍军人事务部改善抗凝治疗研究（VARIA）数据库中的 103897 名在 100 个地点接受华法林治疗的患者。
主要观察指标
结果包括治疗范围内时间百分比（TTR），这是衡量抗凝控制的一个指标，以及 ICD-9 编码的大出血事件。
结果
非使用者的平均 TTR（62%）高于酗酒者（53%）、药物滥用者（50%）或两者兼有者（44%，p<0.001）。在酗酒者中，血清肝转氨酶天冬氨酸氨基转移酶/丙氨酸氨基转移酶（AST：ALT）比值的增加与抗凝控制不良相关；正常 AST：ALT≤1.5 预测 TTR 相对适度下降（54%，p<0.001），而比值升高（AST：ALT 1.50-2.0 和>2.0）则预示着抗凝控制越来越差（49%和 44%，p<0.001 与非使用者相比）。药物滥用和酒精滥用的主要出血风险的年龄调整后的危险比分别为 1.93 和 1.37（与非使用者相比，p<0.001），并且在控制抗凝控制和其他出血风险因素后仍然具有统计学意义（1.69，p<0.001 和 1.22，p=0.003）。在酗酒者中，AST：ALT 升高>2.0 对应于出血增加三倍以上（HR 3.02，p<0.001 与非使用者相比），而正常比值 AST：ALT≤1.5 预测出血率与非使用者相似（HR 1.19，p<0.05）。
结论
在滥用物质的患者中，抗凝控制尤其差。酒精和药物使用者的大出血更为常见。在酗酒者中，AST/ALT 比值有望确定发生不良事件的风险最高的人群。
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