Shafeeq Hira, Tran Tran H
P T. 2014 Jan;39(1):54-64.
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the U.S. Anticoagulation is recommended for stroke prevention in AF patients with intermediate-to-high stroke risk (i.e., patients with a CHADS2 score of 1 or greater). Warfarin was previously the only option for oral anticoagulation in these patients, but three new oral anticoagulants have become available as alternatives for warfarin in patients with nonvalvular AF. The advantages of the newer agents include a rapid onset, predictable pharmacokinetics, and no need for routine anticoagulation monitoring. Dabigatran (Pradaxa) and apixaban (Eliquis) have demonstrated improved efficacy compared with warfarin. Rivaroxaban (Xarelto) was non-inferior to warfarin for stroke prevention in AF. Apixaban demonstrated a reduced incidence of major bleeding compared with warfarin and a reduction in all-cause mortality. Limitations to the use of the new oral anticoagulants include the lack of a reversal agent; an inability to use the therapies in specific patient populations (such as those with severe renal or hepatic impairment); limited experience with drug-drug and drug-disease interactions; and a lack of available coagulation tests to quantify their effects. Although the newer agents have higher acquisition costs, the benefits of cost savings may be derived from the potential for decreasing the incidence of hemorrhagic stroke and intracranial bleeding and reducing the need for anticoagulation monitoring. Benefits and risks should be carefully weighed before these agents are prescribed for patients presenting with new-onset AF.
心房颤动（AF）是美国最常见的心律失常。对于中风风险为中度至高度的AF患者（即CHADS2评分≥1分的患者），建议进行抗凝治疗以预防中风。华法林曾是这些患者口服抗凝的唯一选择，但三种新型口服抗凝剂已成为非瓣膜性AF患者替代华法林的选择。新型药物的优点包括起效迅速、药代动力学可预测，且无需常规抗凝监测。达比加群（Pradaxa）和阿哌沙班（Eliquis）已证明与华法林相比疗效更佳。利伐沙班（Xarelto）在预防AF患者中风方面不劣于华法林。阿哌沙班与华法林相比，大出血发生率降低，全因死亡率也有所降低。新型口服抗凝剂的使用局限性包括缺乏逆转剂；无法在特定患者群体（如严重肾或肝功能损害患者）中使用这些疗法；药物相互作用和药物与疾病相互作用的经验有限；以及缺乏可用的凝血试验来量化其效果。尽管新型药物的采购成本较高，但成本节约的益处可能源于降低出血性中风和颅内出血发生率以及减少抗凝监测需求的可能性。在为新发AF患者开这些药物之前，应仔细权衡其益处和风险。
