在心房颤动中，经验评分与医生评估的中风和出血风险之间缺乏一致性：来自 Outcomes Registry for Better Informed Treatment of Atrial Fibrillation（ORBIT-AF）登记处的结果。
Lack of concordance between empirical scores and physician assessments of stroke and bleeding risk in atrial fibrillation: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry.
机构信息
From the Duke University Medical Center, Durham, NC (B.A.S., J.P.P., E.D.P.); Duke Clinical Research Institute, Durham, NC (B.A.S., S.K., L.T., J.P.P., E.D.P.); UCLA School of Medicine, Los Angeles, CA (G.C.F.); Boston University School of Medicine, Boston, MA (E.H.); New York University School of Medicine, Lenox Hill Hospital, New York, NY (J.A.); Kaiser Permanente, Oakland, CA (A.S.G.); Janssen Pharmaceuticals, Inc., Raritan, NJ (P.C.); Lankenau Institute for Medical Research, Wynnewood, PA (P.K.); Mayo Clinic, Rochester, MN (B.J.G.); Stanford University School of Medicine, Palo Alto, CA (K.W.M.); and Harvard Medical School and Massachusetts General Hospital, Boston, MA (D.E.S.).
出版信息
Circulation. 2014 May 20;129(20):2005-12. doi: 10.1161/CIRCULATIONAHA.114.008643. Epub 2014 Mar 29.
BACKGROUND
Physicians treating patients with atrial fibrillation (AF) must weigh the benefits of anticoagulation in preventing stroke versus the risk of bleeding. Although empirical models have been developed to predict such risks, the degree to which these coincide with clinicians' estimates is unclear.
METHODS AND RESULTS
We examined 10 094 AF patients enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF) registry between June 2010 and August 2011. Empirical stroke and bleeding risks were assessed by using the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke or transient ischemic attack (CHADS2) and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) scores, respectively. Separately, physicians were asked to categorize their patients' stroke and bleeding risks: low risk (<3%); intermediate risk (3%-6%); and high risk (>6%). Overall, 72% (n=7251) in ORBIT-AF had high-risk CHADS2 scores (≥2). However, only 16% were assessed as high stroke risk by physicians. Although 17% (n=1749) had high ATRIA bleeding risk (score ≥5), only 7% (n=719) were considered so by physicians. The associations between empirical and physician-estimated stroke and bleeding risks were low (weighted Kappa 0.1 and 0.11, respectively). Physicians weighed hypertension, heart failure, and diabetes mellitus less significantly than empirical models in estimating stroke risk; physicians weighted anemia and dialysis less significantly than empirical models when estimating bleeding risks. Anticoagulation use was highest among patients with high stroke risk, assessed by either empirical model or physician estimates. In contrast, physician and empirical estimates of bleeding had limited impact on treatment choice.
CONCLUSIONS
There is little agreement between provider-assessed risk and empirical scores in AF. These differences may explain, in part, the current divergence of anticoagulation treatment decisions from guideline recommendations.
CLINICAL TRIAL REGISTRATION URL
http://www.clinicaltrials.gov. Unique identifier: NCT01165710.
背景
治疗心房颤动（AF）患者的医生必须权衡抗凝治疗预防中风的益处与出血风险。尽管已经开发出经验模型来预测这些风险，但这些模型与临床医生的估计之间的吻合程度尚不清楚。
方法和结果
我们检查了 2010 年 6 月至 2011 年 8 月期间在 Outcomes Registry for Better Informed Treatment of AF（ORBIT-AF）登记处登记的 10094 例 AF 患者。分别使用充血性心力衰竭、高血压、年龄≥75 岁、糖尿病和先前的中风或短暂性脑缺血发作（CHADS2）和抗凝和心房颤动危险因素（ATRIA）评分评估经验性中风和出血风险。另外，医生被要求对患者的中风和出血风险进行分类：低风险（<3%）；中风险（3%-6%）；高风险（>6%）。总体而言，ORBIT-AF 中有 72%（n=7251）患者的 CHADS2 评分较高（≥2）。然而，只有 16%的患者被医生评估为高中风风险。尽管有 17%（n=1749）患者的 ATRIA 出血风险较高（评分≥5），但只有 7%（n=719）的患者被医生评估为高出血风险。经验性和医生估计的中风和出血风险之间的相关性较低（加权 Kappa 分别为 0.1 和 0.11）。在估计中风风险时，医生对高血压、心力衰竭和糖尿病的重视程度低于经验模型；在估计出血风险时，医生对贫血和透析的重视程度低于经验模型。在中风风险较高的患者中，抗凝治疗的使用率最高，无论是通过经验模型还是医生评估。相比之下，医生和经验估计的出血对治疗选择的影响有限。
结论
提供者评估的风险与 AF 中的经验评分之间存在差异。这些差异可能部分解释了目前抗凝治疗决策与指南建议之间的分歧。
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