Shroff Gautam R, Solid Craig A, Bloomgarden Zachary, Halperin Jonathan L, Herzog Charles A
Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA.
Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA.
J Diabetes. 2017 Feb;9(2):115-122. doi: 10.1111/1753-0407.12392. Epub 2016 Apr 13.
Diabetes is an important risk factor for ischemic stroke in non-valvular atrial fibrillation (AF). The aim of the present study was to evaluate temporal trends in ischemic stroke and warfarin use among US Medicare patients with and without diabetes.
In this retrospective cohort study, 1-year cohorts of patients with Medicare as the primary payer over the period 1992-2010 were created using the Medicare 5% sample (excluding patients with valvular disease and end-stage renal disease). International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify AF, ischemic and hemorrhagic stroke, and diabetes; three or more consecutive prothrombin time claims were used to identify warfarin use.
Demographic characteristics of subjects in 1992 (n = 40 255) and 2010 (n = 80 314), respectively, were as follows: age 65-74 years, 37% and 32%; age >85 years, 20% and 25%; White, 94% and 93%; hypertension, 46% and 80%; diabetes, 20% and 32%; and chronic kidney disease, 5% and 18%. Among Medicare AF patients with diabetes, ischemic stroke decreased by 71% (1992-2010) from 65 to 19 per 1000 patient-years; warfarin use increased from 28% to 62%. Among patients without diabetes, ischemic stroke decreased by 68% from 44 to 14 per 1000 patient-years, whereas warfarin use increased from 26% to 59%. Approximately 38% of Medicare AF patients with diabetes did not receive anticoagulation in 2010.
Ischemic stroke declined and warfarin use increased similarly in Medicare patients with and without diabetes. Ischemic stroke rates were consistently higher in diabetes patients, validating the inclusion of diabetes in risk calculators. The population of Medicare patients with diabetes who did not receive warfarin deserves future attention.
糖尿病是非瓣膜性心房颤动（AF）患者发生缺血性卒中的重要危险因素。本研究旨在评估美国医疗保险患者中，有无糖尿病者缺血性卒中和华法林使用情况的时间趋势。
在这项回顾性队列研究中，利用医疗保险5%样本（不包括瓣膜病和终末期肾病患者）创建了1992 - 2010年期间以医疗保险作为主要支付方的患者的1年队列。使用国际疾病分类第九版临床修订本（ICD - 9 - CM）编码来识别房颤、缺血性和出血性卒中以及糖尿病；连续三次或更多次凝血酶原时间申请用于识别华法林的使用情况。
1992年（n = 40255）和2010年（n = 80314）受试者的人口统计学特征分别如下：年龄65 - 74岁，分别为37%和32%；年龄>85岁，分别为20%和25%；白人，分别为94%和93%；高血压，分别为46%和80%；糖尿病，分别为20%和32%；慢性肾病，分别为5%和18%。在患有糖尿病的医疗保险房颤患者中，缺血性卒中从1992年至2010年每1000患者年从65例降至19例，降幅为71%；华法林的使用从28%增至62%。在无糖尿病患者中，缺血性卒中从每1000患者年44例降至14例，降幅为68%，而华法林的使用从26%增至59%。2010年，约38%患有糖尿病的医疗保险房颤患者未接受抗凝治疗。
有糖尿病和无糖尿病的医疗保险患者中，缺血性卒中发生率均下降，华法林使用情况均增加。糖尿病患者的缺血性卒中发生率始终较高，这证实了将糖尿病纳入风险计算器的合理性。未接受华法林治疗的患有糖尿病的医疗保险患者群体值得未来关注。
