Gorzelak Paulina, Zyzak Sandra, Krewko Łukasz, Mozdzan Monika, Broncel Marlena
Pol Merkur Lekarski. 2014 May;36(215):302-6.
The incidence of atrial fibrillation (AF) and of thromboembolic complications increases along with age. This is also the case for cognitive function disturbances; therefore their occurrence in patients (pts) with AF may hamper control of anticoagulant therapy and maintenance of therapeutic INR values. The aim of the study was to evaluate the effect of cognitive function disturbances on implementation and monitoring of the treatment with oral vitamin K antagonists (VKA) in patients with AF. The relationship between the level of cognitive function disturbances and the severity of experienced AF symptoms was defined.
The analysis included a group of 93 pts (41 males, 52 females, mean age: 76.8) with a diagnosis of AF and with indications for anticoagulation treatment with VKAs (CHA2DS2VASc > or = 2, HAS-BLED < 3), referred to the Clinic of Internal Diseases and Clinical Pharmacology of the Medical University of Lodz. In a group of pts (n = 46) treated chronically with VKAs, mean INR values at admission to the hospital were calculated and the number of results falling within the therapeutic range of 2-3, by the severity of cognitive disturbances, was analyzed. Cognitive abilities were assessed with the Mini Mental State Examination Scale (MMSE) (MMSE-Mini-mental state examination). The EHRA (European Heart Rhythm Association) classification was used to assess AF-related complaints.
The 93 studied subjects were divided into 3 groups: group I with normal cognitive function (MMSE = 24-27) - n = 35; group II with disturbances of cognitive function without dementia (MMSE = 24-26) - n = 35 and group III with dementia (MMSE < 24) - n = 23.66% of pts with normal MMSE result were referred to the hospital because AF-related symptoms and in the group of patients with MMSE < 24 these symptoms were the cause of hospitalization in 23% of pts. Despite the fact that all patients had indications for VKAs, this treatment was not started in 40%, 51.4% and 65% of pts in group I, II and III, respectively. At admission to the hospital, therapeutic level INR values were found only in 34.8% of AF pts. 49% of pts were treated with VKAs in total. In group II, a high percentage of patients (43%) treated with aspirin was found in spite of high thromboembolic risk and no contraindications to VKAs. About 23% of pts with a normal MMSE result and 14% of pts in group II experienced AF-related symptoms preventing them from normal functioning and performing daily activities (EHRA IV). Nobody in group III reported severe AF-related symptoms.
Along with the advancing age, there is an increase of the incidence of persistent and fixed atrial fibrillation, of the risk of thromboembolic complications and of the severity of cognitive function disturbances. Treatment with oral vitamin K antagonists was implemented much less frequently among patients with atrial fibrillation and cognitive function disturbances, as compared to the patients with normal cognitive function. The MMSE test should be routinely performed in patients with atrial fibrillation to monitor the efficacy and safety of the treatment with oral vitamin K antagonists properly. In patients with disturbances of cognitive function, significantly lower reportability of AF-related complaints was shown, as compared to individuals without these disturbances. Patients with normal MMSE result were referred to the hospital because AF-related symptoms, in the group of patients with MMSE < 23 the main reason for hospitalization was the severity of the symptoms heart failure. ECG should be a routine test performed in elderly patients with cognitive function disturbances or with dementia to detect atrial fibrillation.
心房颤动（AF）及血栓栓塞并发症的发生率随年龄增长而增加。认知功能障碍的情况亦是如此；因此，房颤患者中出现认知功能障碍可能会妨碍抗凝治疗的控制及治疗性国际标准化比值（INR）的维持。本研究旨在评估认知功能障碍对房颤患者口服维生素K拮抗剂（VKA）治疗的实施及监测的影响。明确了认知功能障碍程度与房颤症状严重程度之间的关系。
分析纳入了93例诊断为房颤且有VKA抗凝治疗指征（CHA2DS2VASc≥2，HAS-BLED＜3）的患者（41例男性，52例女性，平均年龄：76.8岁），这些患者被转诊至罗兹医科大学内科及临床药理学诊所。在一组长期接受VKA治疗的患者（n = 46）中，计算入院时的平均INR值，并按认知障碍严重程度分析处于2 - 3治疗范围内的结果数量。使用简易精神状态检查表（MMSE）评估认知能力。采用欧洲心律协会（EHRA）分类法评估房颤相关症状。
93例研究对象分为3组：认知功能正常组（MMSE = 24 - 27） - n = 35；认知功能障碍但无痴呆组（MMSE = 24 - 26） - n = 35；痴呆组（MMSE＜24） - n = 23。MMSE结果正常的患者中66%因房颤相关症状入院，而MMSE＜24的患者组中，这些症状导致23%的患者入院。尽管所有患者都有VKA治疗指征，但I组、II组和III组分别有40%、51.4%和65%的患者未开始该治疗。入院时，仅34.8%的房颤患者INR值处于治疗水平。总共49%的患者接受了VKA治疗。在II组中，尽管血栓栓塞风险高且无VKA治疗禁忌证，但仍有高比例患者（43%）接受阿司匹林治疗。MMSE结果正常的患者中约23%以及II组中14%的患者经历了妨碍其正常功能和日常活动的房颤相关症状（EHRA IV级）。III组中无人报告严重的房颤相关症状。
随着年龄增长，持续性和永久性房颤的发生率、血栓栓塞并发症风险及认知功能障碍严重程度均增加。与认知功能正常的患者相比，房颤合并认知功能障碍患者口服维生素K拮抗剂治疗的实施频率要低得多。应在房颤患者中常规进行MMSE测试，以正确监测口服维生素K拮抗剂治疗的疗效和安全性。与无这些障碍的个体相比，认知功能障碍患者房颤相关症状的报告率显著更低。MMSE结果正常的患者因房颤相关症状入院，在MMSE＜23的患者组中，住院的主要原因是心力衰竭症状严重。心电图应作为认知功能障碍或痴呆老年患者的常规检查，以检测房颤。
