University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom2Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
JAMA. 2015 May 19;313(19):1950-62. doi: 10.1001/jama.2015.4369.
Atrial fibrillation (AF) is associated with an increase in mortality and morbidity, with a substantial increase in stroke and systemic thromboembolism. Strokes related to AF are associated with higher mortality, greater disability, longer hospital stays, and lower chance of being discharged home than strokes unrelated to AF.
To provide an overview of current concepts and recent developments in stroke prevention in AF, with suggestions for practical management.
A comprehensive structured literature search was performed using MEDLINE for studies published through March 11, 2015, that reported on AF and stroke, bleeding risk factors, and stroke prevention.
The risk of stroke in AF is reduced by anticoagulant therapy. Thromboprophylaxis can be obtained with vitamin K antagonists (VKA, eg, warfarin) or a non-VKA oral anticoagulant (NOAC). Major guidelines emphasize the important role of oral anticoagulation (OAC) for effective stroke prevention in AF. Initially, clinicians should identify low-risk AF patients who do not require antithrombotic therapy (ie, CHA2DS2-VASc score, 0 for men; 1 for women). Subsequently, patients with at least 1 stroke risk factor (except when the only risk is being a woman) should be offered OAC. A patient's individual risk of bleeding from antithrombotic therapy should be assessed, and modifiable risk factors for bleeding should be addressed (blood pressure control, discontinuing unnecessary medications such as aspirin or nonsteroidal anti-inflammatory drugs). The international normalized ratio should be tightly controlled for patients receiving VKAs.
Stroke prevention is central to the management of AF, irrespective of a rate or rhythm control strategy. Following the initial focus on identifying low-risk patients, all others with 1 or more stroke risk factors should be offered OAC.
心房颤动（AF）与死亡率和发病率增加有关，与中风和全身性血栓栓塞的风险显著增加有关。与 AF 相关的中风比与 AF 无关的中风死亡率更高、残疾程度更大、住院时间更长、出院回家的机会更低。
提供 AF 中风预防的当前概念和最新进展概述，并提出实用管理建议。
使用 MEDLINE 进行了全面的结构化文献搜索，搜索了截至 2015 年 3 月 11 日发表的与 AF 和中风、出血风险因素以及中风预防有关的研究报告。
AF 中风风险可通过抗凝治疗降低。抗血栓预防可通过维生素 K 拮抗剂（VKA，如华法林）或非 VKA 口服抗凝剂（NOAC）获得。主要指南强调了口服抗凝剂（OAC）在 AF 有效中风预防中的重要作用。最初，临床医生应确定不需要抗血栓治疗的低风险 AF 患者（即 CHA2DS2-VASc 评分，男性为 0；女性为 1）。随后，应向至少有 1 个中风风险因素的患者（除了唯一的风险是女性时）提供 OAC。应评估患者抗血栓治疗出血的个体风险，并应解决出血的可改变风险因素（血压控制，停止不必要的药物，如阿司匹林或非甾体抗炎药）。接受 VKAs 的患者应严格控制国际标准化比值。
中风预防是 AF 管理的核心，无论采用何种心率或节律控制策略。在最初关注确定低风险患者之后，所有有 1 个或多个中风风险因素的其他患者都应提供 OAC。
