Yiin Gabriel S C, Howard Dominic P J, Paul Nicola L M, Li Linxin, Mehta Ziyah, Rothwell Peter M
Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK.
J Neurol Neurosurg Psychiatry. 2017 Jan;88(1):12-18. doi: 10.1136/jnnp-2015-311947. Epub 2015 Oct 20.
Prevalence of atrial fibrillation (AF) is increasing, due partly to the ageing population. The Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) Trial, published in 2007, provided strong evidence of the effectiveness of warfarin at age≥80 years, but the impact on incidence of AF-related stroke and peripheral embolic vascular events is uncertain.
We studied age-specific incidence and outcome of all AF-related incident strokes and systemic emboli from 2002 to 2012 in the Oxford Vascular Study.
Of 3096 acute cerebral or peripheral vascular events, 748 (24.2%) were AF-related. Of the 597 disabling/fatal incident ischaemic strokes, 369 occurred at age ≥80 years, of which 124 (33.6%) were in non-anticoagulated patients with known prior AF. There was no reduction in incident AF-related events after 2007 at all ages (n=231 vs 211; adjusted RR=1.11, 0.91 to 1.36, p=0.29) or at age ≥80 (137 vs 135, RR=1.15, 0.94 to 1.40, p=0.17). Scope for improved prevention at older ages was considerable. Among 208 patients with incident AF-related events at age ≥80 and known prior AF, only 19 (9.1%) were anticoagulated. Of the 189 patients not anticoagulated, 166 (87.8%) had no major disability prior to the event and 167 (88·4%) had a high embolism risk score, of whom 139 (83.2%) were also at low risk of complications. Yet, 125/167 (74.9%) were dead or institutionalised after the event. Potentially preventable embolic events outnumbered warfarin-related intracerebral haemorrhages by about 15-fold (280 vs 19), rising to 50-fold (189 vs 4) at age ≥80 years.
We found no reduction in incidence of AF-related vascular events since publication of the BAFTA trial. A third of all disabling/fatal strokes occur in non-anticoagulated patients with known prior AF.
心房颤动（房颤）的患病率正在上升，部分原因是人口老龄化。2007年发表的伯明翰老年人心房颤动治疗（BAFTA）试验提供了强有力的证据，证明华法林在年龄≥80岁时的有效性，但对房颤相关中风和外周栓塞性血管事件发生率的影响尚不确定。
我们在牛津血管研究中研究了2002年至2012年所有房颤相关新发中风和全身性栓塞的年龄特异性发病率及转归。
在3096例急性脑或外周血管事件中，748例（24.2%）与房颤相关。在597例致残性/致死性缺血性中风中，369例发生在年龄≥80岁的患者中，其中124例（33.6%）为已知既往有房颤的未接受抗凝治疗的患者。2化7年之后，各年龄段房颤相关事件的发病率均未降低（n = 231比211；校正风险比=1.11，0.91至1.36，p = 0.29），年龄≥80岁者也未降低（137比135，风险比=1.15，0.94至1.40，p = 0.17）。老年人群中改善预防措施的空间很大。在年龄≥80岁且已知既往有房颤的208例房颤相关事件患者中，仅19例（9.1%）接受了抗凝治疗。在189例未接受抗凝治疗的患者中，166例（87.8%）在事件发生前无严重残疾，167例（88.4%）有高栓塞风险评分，其中139例（83.2%）并发症风险也较低。然而，事件发生后125/167例（74.9%）死亡或进入机构照护。潜在可预防的栓塞事件比华法林相关脑出血多约15倍（280比19），在年龄≥80岁时增至50倍（189比4）。
我们发现自BAFTA试验发表以来，房颤相关血管事件的发病率未降低。所有致残性/致死性中风中有三分之一发生在已知既往有房颤的未接受抗凝治疗的患者中。
