Department of Medicine, Columbia University, New York, NY.
Am J Med. 2014 Apr;127(4):e15. doi: 10.1016/j.amjmed.2013.06.001.
For clinicians, atrial fibrillation (AFib) is not a disease that will probably be "cured" at some point during their professional lifetime. (online video available at: http://education.amjmed.com/video.php?event_id=445&stage_id=5&vcs=1). AFib is a condition that occurs in association with aging, affecting as many as 1 in 10 patients by the time they reach age 85, and therefore all physicians who read The American Journal of Medicine should be aware of AFib-its etiology, how to recognize it, and with some idea of how it is treated. Perhaps the most important aspect of AFib, however, is as a risk factor for systemic embolism and stroke, which means that almost all patients with AFib will need to receive anticoagulation therapy, probably for the rest of their lives. For the past several decades the only oral anticoagulant agent has been warfarin. Warfarin is an effective anticoagulant, but for many reasons (patient adherence, physician reluctance, warfarin's narrow therapeutic efficacy), less than half of the patients who should be anticoagulated are prescribed warfarin (dropping to less than a third in older patients), and of those who are prescribed and apparently adherent, less than a third maintain serum warfarin levels in the narrow therapeutic range of INR 2-3. Thus, it is clear that the traditional prescription of warfarin for patients with AFib has failed to meet an important need for reducing risk of systemic embolism and stroke. Fortunately, however, within the last couple of years a new generation of novel oral anticoagulant (NOAC) agents has proven successful in randomized clinical trials and has been passing through the regulatory approval process. For physicians this represents both a challenge-to learn and understand the evidence base for these new anticoagulant therapies-and the opportunity now to treat their aging patients who are increasingly likely to present with cerebrovascular disease risks and who are depending on their physicians to treat them with the best evidence-based care available today. To address this need this program reviews: the epidemiology and demographics of AFib; risk reduction for the general patient population with AFib; the new oral anticoagulant agents that may offer alternatives to warfarin; risk reduction for the special patient populations (age, gender, triple-therapy patients).
对于临床医生来说，心房颤动（房颤）在其职业生涯中不太可能“治愈”。（在线视频可在以下网址查看：http://education.amjmed.com/video.php?event_id=445&stage_id=5&vcs=1）。房颤是一种随着年龄增长而发生的疾病，在患者达到 85 岁时，多达 10 分之一的患者会出现这种疾病，因此所有阅读《美国医学杂志》的医生都应该了解房颤的病因、如何识别它，以及了解如何治疗它。然而，房颤最重要的方面可能是全身性栓塞和中风的风险因素，这意味着几乎所有房颤患者都需要接受抗凝治疗，可能需要终生接受抗凝治疗。在过去的几十年里，唯一的口服抗凝剂一直是华法林。华法林是一种有效的抗凝剂，但由于多种原因（患者依从性、医生不愿使用、华法林治疗效果狭窄），不到一半应该抗凝的患者被开了华法林（在老年患者中降至不到三分之一），而在开了华法林并明显依从的患者中，不到三分之一的患者将血清华法林水平维持在 INR 2-3 的狭窄治疗范围内。因此，很明显，传统的房颤患者华法林处方未能满足降低全身性栓塞和中风风险的重要需求。幸运的是，然而，在过去几年中，新一代新型口服抗凝剂（NOAC）药物在随机临床试验中已被证明是成功的，并已通过监管批准程序。这对医生来说既是一个挑战——学习和理解这些新型抗凝治疗的证据基础——也是一个机会，现在可以为他们日益老龄化的患者提供治疗，这些患者更有可能出现脑血管疾病风险，并且依赖他们的医生为他们提供当今最好的基于证据的治疗。为了满足这一需求，本项目回顾了：房颤的流行病学和人口统计学；房颤一般患者人群的风险降低；可能替代华法林的新型口服抗凝剂；特殊患者人群（年龄、性别、三联治疗患者）的风险降低。
