Department of Cardiology, Gentofte University Hospital, Hellerup, Copenhagen, Denmark.
University of Birmingham, Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
J Am Coll Cardiol. 2014 Jun 24;63(24):2689-98. doi: 10.1016/j.jacc.2014.03.039. Epub 2014 Apr 30.
The aim of this study was to investigate the impact of atrial fibrillation (AF) and antithrombotic treatment on the prognosis in patients with heart failure (HF) as well as vascular disease.
HF, vascular disease, and AF are pathophysiologically related, and understanding antithrombotic treatment for these conditions is crucial.
In hospitalized patients with HF and coexisting vascular disease (coronary artery disease or peripheral arterial disease) followed from 1997 to 2009, AF status was categorized as prevalent AF, incident AF, or no AF. Risk of thromboembolism (TE), myocardial infarction (MI), and serious bleeding was assessed by Cox regression models (hazard ratio [HR] with 95% confidence interval [CI]) with antithrombotic therapy and AF as time-dependent variables.
A total of 37,464 patients were included (age, 74.5 ± 10.7 years; 36.3% females) with a mean follow-up of 3 years during which 20.7% were categorized as prevalent AF and 17.2% as incident AF. Compared with vitamin K antagonist (VKA) in prevalent AF, VKA plus antiplatelet was not associated with a decreased risk of TE (HR: 0.91; 95% CI: 0.73 to 1.12) or MI (HR: 1.11; 95% CI: 0.96 to 1.28), whereas bleeding risk was significantly increased (HR: 1.31; 95% CI: 1.09 to 1.57). Corresponding estimates for incident AF were HRs of 0.77 (95% CI: 0.56 to 1.06), 1.07 (95% CI: 0.89 to 1.28), and 2.71 (95% CI: 1.33 to 2.21) for TE, MI, and bleeding, respectively. In no AF patients, no statistical differences were seen between antithrombotic therapies in TE or MI risk, whereas bleeding risk was significantly increased for VKA with and without single-antiplatelet therapy.
In AF patients with coexisting HF and vascular disease, adding single-antiplatelet therapy to VKA therapy is not associated with additional benefit in thromboembolic or coronary risk, but notably increased bleeding risk.
本研究旨在探讨心房颤动（AF）和抗血栓治疗对心力衰竭（HF）合并血管疾病患者预后的影响。
HF、血管疾病和 AF 在病理生理学上相互关联，了解这些疾病的抗血栓治疗至关重要。
在 1997 年至 2009 年期间住院的 HF 合并血管疾病（冠状动脉疾病或外周动脉疾病）的患者中，将 AF 状态分为持续性 AF、新发 AF 或无 AF。通过 Cox 回归模型（风险比[HR]及其 95%置信区间[CI]）评估血栓栓塞（TE）、心肌梗死（MI）和严重出血风险，抗血栓治疗和 AF 作为时间依赖性变量。
共纳入 37464 例患者（年龄 74.5±10.7 岁；36.3%为女性），平均随访 3 年，其中 20.7%为持续性 AF，17.2%为新发 AF。与持续性 AF 中的维生素 K 拮抗剂（VKA）相比，VKA 加抗血小板治疗与 TE（HR：0.91；95%CI：0.73 至 1.12）或 MI（HR：1.11；95%CI：0.96 至 1.28）风险降低无关，而出血风险显著增加（HR：1.31；95%CI：1.09 至 1.57）。新发 AF 的相应估计值分别为 TE、MI 和出血的 HR 为 0.77（95%CI：0.56 至 1.06）、1.07（95%CI：0.89 至 1.28）和 2.71（95%CI：1.33 至 2.21）。在无 AF 患者中，抗血栓治疗在 TE 或 MI 风险方面无统计学差异，而 VKA 联合或不联合单一抗血小板治疗的出血风险显著增加。
在合并 HF 和血管疾病的 AF 患者中，VKA 加用单一抗血小板治疗与血栓栓塞或冠状动脉风险的额外获益无关，但出血风险显著增加。
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