Hsu Jonathan C, Chan Paul S, Tang Fengming, Maddox Thomas M, Marcus Gregory M
Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego.
Mid America Heart Institute, Kansas City, Mo.
Am J Med. 2015 Jun;128(6):654.e1-654.e10. doi: 10.1016/j.amjmed.2014.11.035. Epub 2014 Dec 29.
Patients with paroxysmal and persistent atrial fibrillation experience a similar risk of thromboembolism. Therefore, consensus guidelines recommend anticoagulant therapy in those at risk for thromboembolism irrespective of atrial fibrillation classification. We sought to examine whether there are differences in rates of appropriate oral anticoagulant treatment among patients with paroxysmal vs persistent atrial fibrillation in real-world cardiology practices.
We studied 71,316 outpatients with atrial fibrillation and intermediate to high thromboembolic risk (CHADS2 score ≥2) enrolled in the American College of Cardiology PINNACLE Registry between 2008 and 2012. Using hierarchical modified Poisson regression models adjusted for patient characteristics, we examined whether anticoagulant treatment rates differed between patients with paroxysmal vs persistent atrial fibrillation.
The majority of outpatients (78.4%, n = 55,905) had paroxysmal atrial fibrillation. In both unadjusted and multivariable adjusted analyses, patients with paroxysmal atrial fibrillation were less frequently prescribed oral anticoagulant therapy than those with persistent atrial fibrillation (50.3% vs 64.2%; adjusted risk ratio [RR] 0.74; 95% confidence interval [CI], 0.72-0.76). Instead, patients with paroxysmal atrial fibrillation were prescribed more frequently only antiplatelet therapy (35.1% vs 25.0%; adjusted RR 1.77; 95% CI, 1.69-1.86) or neither antiplatelet nor anticoagulant therapy (14.6% vs 10.8%; adjusted RR 1.35; 95% CI, 1.26-1.44; P < .0001 for differences across all 3 comparisons).
In a large, real-world cardiac outpatient population, patients with paroxysmal atrial fibrillation with a moderate to high risk of stroke were less likely to be prescribed appropriate oral anticoagulant therapy and more likely to be prescribed less effective or no therapy for thromboembolism prevention.
阵发性和持续性心房颤动患者发生血栓栓塞的风险相似。因此，共识指南建议对有血栓栓塞风险的患者进行抗凝治疗，而不考虑心房颤动的分类。我们试图研究在现实世界的心脏病学实践中，阵发性与持续性心房颤动患者接受适当口服抗凝治疗的比例是否存在差异。
我们研究了2008年至2012年期间纳入美国心脏病学会PINNACLE注册研究的71316例有中度至高度血栓栓塞风险（CHADS2评分≥2）的心房颤动门诊患者。使用针对患者特征进行调整的分层修正泊松回归模型，我们研究了阵发性与持续性心房颤动患者的抗凝治疗率是否存在差异。
大多数门诊患者（78.4%，n = 55905）患有阵发性心房颤动。在未调整和多变量调整分析中，阵发性心房颤动患者接受口服抗凝治疗的频率低于持续性心房颤动患者（50.3%对64.2%；调整风险比[RR]0.74；95%置信区间[CI]，0.72 - 0.76）。相反，阵发性心房颤动患者更常仅接受抗血小板治疗（35.1%对25.0%；调整RR 1.77；95%CI，1.69 - 1.86）或既不接受抗血小板治疗也不接受抗凝治疗（14.6%对10.8%；调整RR 1.35；95%CI，1.26 - 1.44；所有3项比较的差异P <.0001）。
在一个大型的现实世界心脏门诊人群中，有中度至高度卒中风险的阵发性心房颤动患者接受适当口服抗凝治疗的可能性较小，而接受预防血栓栓塞效果较差或不接受治疗的可能性较大。
