Buss Nicholas I, Friedman Scott E, Andrus Bruce W, DeVries James T
Department of Cardiology, The Geisel School of Medicine at Dartmouth/Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
Coron Artery Dis. 2013 Dec;24(8):636-41. doi: 10.1097/MCA.0000000000000032.
To assess the benefit of vitamin K antagonist (VKA) therapy for prevention of ischemic stroke following anterior ST-elevation myocardial infarction (STEMI) in patients with reduced ejection fraction.
A prospective institutional-based registry was used to identify survivors of anterior STEMI with a post-STEMI ejection fraction of 40% or less over a 10-year period. Clinical and procedural characteristics were collected from medical records and vital status from the Social Security Death Index. Outcomes were compared on the basis of VKA use. The primary outcome was a composite of ischemic stroke, death, and clinically relevant bleeding. A secondary analysis examined the effects of low-molecular-weight heparin bridging therapy.
The primary outcome occurred in 24.7% (40/162) of VKA patients and 20.5% (22/107) of non-VKA patients [adjusted hazard ratio (HR), 1.30; 95% confidence interval (CI), 0.71-2.31]. Ischemic stroke occurred in 2.5 and 0.9% of VKA patients and non-VKA patients, respectively (adjusted HR, 2.81; 95% CI, 0.31-25.1). There was no significant difference in the rate of bleeding or death between groups. The addition of a low-molecular-weight heparin bridge to VKA therapy was associated with increased bleeding events (adjusted HR, 2.55; 95% CI, 1.04-6.24).
Ischemic stroke was infrequent in the 6 months following anterior STEMI irrespective of VKA treatment status. The routine use of anticoagulation for prevention of stroke following anterior STEMI may not be warranted.
评估维生素K拮抗剂（VKA）治疗对射血分数降低的前壁ST段抬高型心肌梗死（STEMI）患者预防缺血性卒中的益处。
采用前瞻性机构注册研究，纳入10年间前壁STEMI幸存者，其STEMI后射血分数为40%或更低。从病历中收集临床和手术特征，并从社会保障死亡指数中获取生命状态信息。根据VKA使用情况比较结局。主要结局为缺血性卒中、死亡和临床相关出血的复合结局。次要分析检查低分子量肝素桥接治疗的效果。
VKA治疗组主要结局发生率为24.7%（40/162），非VKA治疗组为20.5%（22/107）[校正风险比（HR），1.30；95%置信区间（CI），0.71 - 2.31]。缺血性卒中在VKA治疗组和非VKA治疗组中的发生率分别为2.5%和0.9%（校正HR，2.81；95%CI，0.31 - 25.1）。两组间出血或死亡率无显著差异。在VKA治疗基础上加用低分子量肝素桥接治疗与出血事件增加相关（校正HR，2.55；95%CI，1.04 - 6.24）。
无论VKA治疗状态如何，前壁STEMI后6个月内缺血性卒中发生率较低。前壁STEMI后常规使用抗凝药物预防卒中可能并无必要。
