口服抗凝剂依从性对心房颤动患者中风风险和大出血的影响。
Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation.
作者信息
Yao Xiaoxi, Abraham Neena S, Alexander G Caleb, Crown William, Montori Victor M, Sangaralingham Lindsey R, Gersh Bernard J, Shah Nilay D, Noseworthy Peter A
机构信息
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, AZ Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, MN.
出版信息
J Am Heart Assoc. 2016 Feb 23;5(2):e003074. doi: 10.1161/JAHA.115.003074.
BACKGROUND
In comparison to warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) have the advantages of ease of dosing, fewer drug interactions, and lack of need for ongoing monitoring. We sought to evaluate whether these advantages translate to improved adherence and whether adherence is associated with improved outcomes in patients with atrial fibrillation.
METHODS AND RESULTS
We performed a retrospective cohort analysis by using a large US commercial insurance database to identify 64 661 patients with atrial fibrillation who initiated warfarin, dabigatran, rivaroxaban, or apixaban treatment between November 1, 2010, and December 31, 2014. During a median of 1.1 y of follow-up, 47.5% of NOAC patients had a proportion of days covered of ≥80%, compared with 40.2% in warfarin patients (P<0.001). Patients with CHA2DS2-VASc (risk based on the presence of congestive heart failure, hypertension age 65-74 y, age ≥75 y, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, sex category) score ≥4 were at increased risk of stroke when they were not taking anticoagulation ≥1 month versus <1 week (1-3 months: hazard ratio [HR] 1.96, 3-6 months: HR 2.64, ≥6 months: HR 3.66; all P<0.001). Patients with CHA2DS2-VASc score 2 or 3 were at increased risk of stroke when they were not taking anticoagulation ≥6 months (HR 2.73, P<0.001). In these patients with CHA2DS2-VASc score ≥2, nonadherence was not associated with intracranial hemorrhage. Among patients with CHA2DS2-VASc score 0 or 1, time not taking anticoagulation was not associated with stroke, but not taking anticoagulation ≥3 months was associated with a significant reduction of bleeding.
CONCLUSIONS
Adherence to anticoagulation is poor in practice and may be modestly improved with NOACs. Adherence to therapy appears to be most important in patients with CHA2DS2-VASc score ≥2, whereas the benefits of anticoagulation may not outweigh the harms in patients with CHA2DS2-VASc score 0 or 1.
背景
与华法林相比，非维生素K拮抗剂口服抗凝药（NOACs）具有给药方便、药物相互作用少以及无需持续监测的优点。我们试图评估这些优点是否能转化为更好的依从性，以及依从性是否与房颤患者更好的预后相关。
方法与结果
我们利用美国一个大型商业保险数据库进行了一项回顾性队列分析，以确定2010年11月1日至2014年12月31日期间开始使用华法林、达比加群、利伐沙班或阿哌沙班治疗的64661例房颤患者。在中位随访1.1年期间，47.5%的NOAC患者的服药天数比例≥80%，而华法林患者为40.2%（P<0.001）。CHA2DS2-VASc（基于充血性心力衰竭、高血压、年龄65 - 74岁、年龄≥75岁、糖尿病、既往卒中或短暂性脑缺血发作、血管疾病、性别分类的风险）评分≥4的患者，未服用抗凝药≥1个月时卒中风险高于未服用<1周（1 - 3个月：风险比[HR]1.96，3 - 6个月：HR 2.64，≥6个月：HR 3.66；均P<0.001）。CHA2DS2-VASc评分为2或3的患者，未服用抗凝药≥6个月时卒中风险增加（HR 2.73，P<0.001）。在这些CHA2DS2-VASc评分≥2的患者中，不依从与颅内出血无关。在CHA2DS2-VASc评分为0或1的患者中，未服用抗凝药的时间与卒中无关，但未服用抗凝药≥3个月与出血显著减少相关。
结论
在实际中抗凝治疗的依从性较差，使用NOACs可能会稍有改善。对于CHA2DS2-VASc评分≥2的患者，坚持治疗似乎最为重要，而对于CHA2DS2-VASc评分为0或1的患者，抗凝治疗的益处可能并不大于危害。
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