Gumbinger Christoph, Holstein Timo, Stock Christian, Rizos Timolaos, Horstmann Solveig, Veltkamp Roland
Department of Neurology, University of Heidelberg, Heidelberg, Germany.
Eur Neurol. 2015;73(3-4):184-91. doi: 10.1159/000371574. Epub 2015 Jan 24.
Although long-term oral anticoagulation (OAC) with vitamin K antagonists for secondary stroke prevention in atrial fibrillation (AF) is highly effective, it is frequently not started or discontinued in clinical practice. We analyzed the reasons for stroke patients' and physician's nonadherence.
In this prospective, observational, single-center cohort study, consecutive patients diagnosed with acute ischemic stroke or transient ischemic attack (TIA) and AF presenting during a nine-month period were included. Adherence to OAC was evaluated at 15 ± 1 months after the event using a semi-structured telephone interview. In patients without anticoagulation, the primary care physician (PCP) was contacted to explore the reason. Associations between nonadherence to OAC therapy at follow-up and potential predictors were assessed by logistic regression analysis.
Of the 1,049 presenting stroke/TIA patients, 139 with a first (n = 101) or a continued recommendation (n = 38) of OAC were analyzed. After 15 months, 54 patients (39% of 85 patients with OAC at follow-up) were nonadherent. The main reasons for patients' nonadherence were fear of side effects (e.g., bleeding) and inconvenience of regular international normalized ratio measurements. In two-thirds (36/54) of cases, OAC was not prescribed by the PCP; the most important reasons were a putative high risk of falling and dementia. Risk factors for nonadherence were dementia, living in a nursing home, and the noninitiation of OAC during in-hospital stay. Treatment was temporarily discontinued in 21 (25%) of patients on OAC at follow-up.
Nonadherence to OAC in stroke patients results from fear of potential complications or inconvenience and physicians' concerns regarding functional status. OAC should be initiated wherever possible during the in-hospital stay.
尽管长期使用维生素K拮抗剂进行口服抗凝治疗（OAC）以预防心房颤动（AF）继发中风非常有效，但在临床实践中，这种治疗常常未被启动或中断。我们分析了中风患者和医生不依从治疗的原因。
在这项前瞻性、观察性、单中心队列研究中，纳入了在9个月期间连续诊断为急性缺血性中风或短暂性脑缺血发作（TIA）且伴有AF的患者。在事件发生后15±1个月，通过半结构化电话访谈评估对OAC的依从性。对于未进行抗凝治疗的患者，联系其初级保健医生（PCP）以探究原因。通过逻辑回归分析评估随访时OAC治疗不依从与潜在预测因素之间的关联。
在1049例出现中风/TIA的患者中，分析了139例首次（n = 101）或持续推荐（n = 38）进行OAC治疗的患者。15个月后，54例患者（随访时接受OAC治疗的85例患者中的39%）未依从治疗。患者不依从的主要原因是担心副作用（如出血）以及定期进行国际标准化比值测量带来的不便。在三分之二（36/54）的病例中，PCP未开具OAC处方；最重要的原因是推测跌倒和痴呆风险高。不依从的风险因素包括痴呆、住在养老院以及住院期间未启动OAC治疗。随访时，21例（25%）接受OAC治疗的患者暂时中断了治疗。
中风患者不依从OAC治疗是由于担心潜在并发症或不便以及医生对功能状态的担忧。应尽可能在住院期间启动OAC治疗。
