Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea.
J Stroke. 2014 May;16(2):73-80. doi: 10.5853/jos.2014.16.2.73. Epub 2014 May 30.
Atrial fibrillation (AF) is an emerging epidemic in both high-income and low-income countries, mainly because of global population aging. Stroke is a major complication of AF, and AF-related ischemic stroke is more disabling and more fatal than other types of ischemic stroke. However, because of concerns about bleeding complications, particularly intracranial hemorrhage, and the limitations of a narrow therapeutic window, warfarin is underused. Four large phase III randomized controlled trials in patients with non-valvular AF (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48) demonstrated that new oral anticoagulants (NOACs) are superior or non-inferior to warfarin as regards their efficacy in preventing ischemic stroke and systemic embolism, and superior to warfarin in terms of intracranial hemorrhage. Among AF patients receiving warfarin, Asians compared to non-Asians are at higher risk of stroke or systemic embolism and are also more prone to develop major bleeding complications, including intracranial hemorrhage. The extra benefit offered by NOACs over warfarin appears to be greater in Asians than in non-Asians. In addition, Asians are less compliant, partly because of the frequent use of herbal remedies. Therefore, NOACs compared to warfarin may be safer and more useful in Asians than in non-Asians, especially in stroke patients. Although the use of NOACs in AF patients is rapidly increasing, guidelines for the insurance reimbursement of NOACs have not been resolved, partly because of insufficient understanding of the benefit of NOACs and partly because of cost concerns. The cost-effectiveness of NOACs has been well demonstrated in the healthcare settings of developed countries, and its magnitude would vary depending on population characteristics as well as treatment cost. Therefore, academic societies and regulatory authorities should work together to formulate a scientific healthcare policy that will effectively reduce the burden of AF-related stroke in this rapidly aging society.
心房颤动（AF）在高收入和低收入国家都是一种新兴的流行疾病，主要是由于全球人口老龄化。中风是 AF 的主要并发症，AF 相关的缺血性中风比其他类型的缺血性中风更具致残性和致命性。然而，由于担心出血并发症，特别是颅内出血，以及治疗窗口狭窄的限制，华法林的使用不足。四项大型 III 期随机对照试验（RE-LY、ROCKET-AF、ARISTOTLE 和 ENGAGE-AF-TIMI 48）表明，新型口服抗凝剂（NOACs）在预防缺血性中风和全身性栓塞方面优于或不劣于华法林，在颅内出血方面优于华法林。在接受华法林治疗的 AF 患者中，亚洲人比非亚洲人发生中风或全身性栓塞的风险更高，也更容易发生大出血并发症，包括颅内出血。NOACs 比华法林提供的额外益处似乎在亚洲人中比非亚洲人中更大。此外，亚洲人依从性较差，部分原因是经常使用草药。因此，NOACs 可能比华法林在亚洲人中更安全、更有用，尤其是在中风患者中。尽管 AF 患者中 NOACs 的使用正在迅速增加，但 NOACs 的保险报销指南尚未解决，部分原因是对 NOACs 的益处了解不足，部分原因是成本问题。NOACs 在发达国家的医疗保健环境中的成本效益已得到充分证明，其规模将取决于人口特征以及治疗成本。因此，学术协会和监管机构应共同努力，制定科学的医疗保健政策，以有效减轻这个快速老龄化社会中与 AF 相关的中风负担。
