优化心房颤动患者的卒中预防：GRASP-AF审核工具在英国全科医疗队列中的应用
Optimising stroke prevention in patients with atrial fibrillation: application of the GRASP-AF audit tool in a UK general practice cohort.
作者信息
Shantsila Eduard, Wolff Andreas, Lip Gregory Y H, Lane Deirdre A
机构信息
University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham.
Whinfield Medical Practice, Darlington.
出版信息
Br J Gen Pract. 2015 Jan;65(630):e16-23. doi: 10.3399/bjgp15X683113.
BACKGROUND
Oral anticoagulation (OAC) is recommended for effective stroke prevention in the majority of atrial fibrillation patients but is often under-utilised.
AIM
To use the Guidance on Risk Assessment and Stroke Prevention in the Atrial Fibrillation (GRASP-AF) tool to risk stratify patients, identify antithrombotic therapy received, and determine predictors of stroke and death in a UK general practice cohort.
DESIGN AND SETTING
Retrospective-observational cohort study in 11 general practices in Darlington, England, with 105 000 patients.
METHOD
The study included patients with atrial fibrillation (AF) identified from GP databases using the GRASP-AF tool. Stroke risk was determined by CHADS2 and CHA2DS2-VASc scores.
RESULTS
A total of 2259 (2.15%) patients with AF (mean age 76 years [SD 12]; 46% female) were identified. Use of CHA2DS2-VASc rather than CHADS2 increased the proportion eligible for OAC from 86.0% to 92.5%. Of those with CHA2DS2-VASc score of ≥2, 39.7% were not receiving appropriate OAC, and of those with CHADS2 score of ≥1, 39.5% were not receiving appropriate OAC. Antiplatelet monotherapy was utilised in 33-40% of patients at high risk of stroke. During 12-month follow-up, 67 (3.0%) patients experienced a stroke and 214 (9.5%) died. Use of OAC significantly reduced stroke risk (odds ratio [OR] 0.60, 95% confidence intervals [CI] = 0.45 to 0.81) and death (OR = 0.54, 95% CI = 0.38 to 0.75, P<0.001) among patients at moderate-high risk of stroke. Use of antiplatelet agents also independently predicted death (OR = 0.69, 95% CI = 0.50 to 0.94; P = 0.020).
CONCLUSION
Most patients with AF in general practice are at high risk of stroke, but OAC is under-utilised in about 40%. Risk of stroke and death was significantly reduced by OAC, yet antiplatelet monotherapy was inappropriately used in approximately 25% of patients at risk of stroke. Optimal implementation of the CHA2DS2-VASc score in the GRASP-AF tool could help prevent more strokes annually.
背景
对于大多数房颤患者，推荐使用口服抗凝药（OAC）进行有效的卒中预防，但OAC的使用常常不足。
目的
使用房颤风险评估与卒中预防指南（GRASP-AF）工具对患者进行风险分层，确定接受的抗栓治疗，并确定英国基层医疗队列中卒中及死亡的预测因素。
设计与设置
在英格兰达灵顿的11家基层医疗机构进行的回顾性观察队列研究，涉及105000名患者。
方法
该研究纳入了使用GRASP-AF工具从全科医生数据库中识别出的房颤（AF）患者。通过CHADS2和CHA2DS2-VASc评分确定卒中风险。
结果
共识别出2259名（2.15%）房颤患者（平均年龄76岁[标准差12]；46%为女性）。使用CHA2DS2-VASc而非CHADS2评分，使符合OAC治疗条件的患者比例从86.0%增至92.5%。在CHA2DS2-VASc评分≥2的患者中，39.7%未接受适当的OAC治疗；在CHADS2评分≥1的患者中，39.5%未接受适当的OAC治疗。33%-40%的卒中高危患者使用了抗血小板单药治疗。在12个月的随访期间，67名（3.0%）患者发生了卒中，214名（9.5%）患者死亡。在中高危卒中风险患者中，使用OAC显著降低了卒中风险（比值比[OR]0.60，95%置信区间[CI]=0.45至0.81）和死亡风险（OR=0.54，95%CI=0.38至0.75，P<0.001）。使用抗血小板药物也独立预测了死亡（OR=0.69，95%CI=0.50至0.94；P=0.020）。
结论
在基层医疗中，大多数房颤患者有较高的卒中风险，但约40%的患者未充分使用OAC。OAC显著降低了卒中和死亡风险，但约25%的卒中风险患者不恰当地使用了抗血小板单药治疗。在GRASP-AF工具中最佳实施CHA2DS2-VASc评分有助于每年预防更多的卒中。
Zotero 插件