口服抗凝剂治疗的心房颤动患者稳定型冠状动脉疾病的抗血小板治疗：一项全国性队列研究。
Antiplatelet therapy for stable coronary artery disease in atrial fibrillation patients taking an oral anticoagulant: a nationwide cohort study.
机构信息
Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L., G.H.G., J.B.O., A.P.M., R.S., M.L.H.); National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark (G.H.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Cardiology B, Aarhus University Hospital, Skejby, Denmark (J.F.L.); Department of Cardiology, the Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark (L.K.); and Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.).
出版信息
Circulation. 2014 Apr 15;129(15):1577-85. doi: 10.1161/CIRCULATIONAHA.113.004834. Epub 2014 Jan 27.
BACKGROUND
The optimal long-term antithrombotic treatment of patients with coexisting atrial fibrillation and stable coronary artery disease is unresolved, and commonly, a single antiplatelet agent is added to oral anticoagulation. We investigated the effectiveness and safety of adding antiplatelet therapy to vitamin K antagonist (VKA) in atrial fibrillation patents with stable coronary artery disease.
METHODS AND RESULTS
Atrial fibrillation patients with stable coronary artery disease (defined as 12 months from an acute coronary event) between 2002 and 2011 were identified. The subsequent risk of cardiovascular events and serious bleeding events (those that required hospitalization) was examined with adjusted Cox regression models according to ongoing antithrombotic therapy. A total of 8700 patients were included (mean age, 74.2 years; 38% women). During a mean follow-up of 3.3 years, crude incidence rates were 7.2, 3.8, and 4.0 events per 100 person-years for myocardial infarction/coronary death, thromboembolism, and serious bleeding, respectively. Relative to VKA monotherapy, the risk of myocardial infarction/coronary death was similar for VKA plus aspirin (hazard ratio, 1.12 [95% confidence interval, 0.94-1.34]) and VKA plus clopidogrel (hazard ratio, 1.53 [95% confidence interval, 0.93-2.52]). The risk of thromboembolism was comparable in all regimens that included VKA, whereas the risk of bleeding increased when aspirin (hazard ratio, 1.50 [95% confidence interval, 1.23-1.82]) or clopidogrel (hazard ratio, 1.84 [95% confidence interval, 1.11-3.06]) was added to VKA.
CONCLUSIONS
In atrial fibrillation patients with stable coronary artery disease, the addition of antiplatelet therapy to VKA therapy is not associated with a reduction in risk of recurrent coronary events or thromboembolism, whereas risk of bleeding is increased significantly. The common practice of adding antiplatelet therapy to oral VKA anticoagulation in patients with atrial fibrillation and stable coronary artery disease warrants reassessment.
背景
同时患有心房颤动和稳定型冠状动脉疾病的患者的最佳长期抗血栓治疗仍未解决，通常会在口服抗凝治疗的基础上加用单一抗血小板药物。我们研究了在稳定型冠状动脉疾病的心房颤动患者中添加抗血小板治疗对维生素 K 拮抗剂（VKA）的疗效和安全性。
方法和结果
2002 年至 2011 年间，我们确定了患有稳定型冠状动脉疾病（定义为急性冠状动脉事件发生后 12 个月）的心房颤动患者。根据正在进行的抗血栓治疗，使用调整后的 Cox 回归模型检查随后发生心血管事件和严重出血事件（需要住院治疗的事件）的风险。共纳入 8700 例患者（平均年龄 74.2 岁，38%为女性）。在平均 3.3 年的随访期间，心肌梗死/冠状动脉死亡、血栓栓塞和严重出血的粗发生率分别为每 100 人年 7.2、3.8 和 4.0 例。与 VKA 单药治疗相比，VKA 加阿司匹林（危险比，1.12[95%置信区间，0.94-1.34]）和 VKA 加氯吡格雷（危险比，1.53[95%置信区间，0.93-2.52]）的心肌梗死/冠状动脉死亡风险相似。所有包含 VKA 的方案中，血栓栓塞的风险均相当，而当阿司匹林（危险比，1.50[95%置信区间，1.23-1.82]）或氯吡格雷（危险比，1.84[95%置信区间，1.11-3.06]）加用 VKA 时，出血风险增加。
结论
在稳定型冠状动脉疾病的心房颤动患者中，VKA 治疗中添加抗血小板治疗并不能降低复发性冠状动脉事件或血栓栓塞的风险，而出血风险显著增加。在心房颤动和稳定型冠状动脉疾病患者中，将抗血小板治疗添加到口服 VKA 抗凝治疗中的常见做法需要重新评估。
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