Chan Esther W, Lau Wallis C Y, Siu Chung Wah, Lip Gregory Y H, Leung Wai K, Anand Shweta, Man Kenneth K C, Wong Ian C K
Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.
Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.
Heart Rhythm. 2016 Aug;13(8):1581-8. doi: 10.1016/j.hrthm.2016.03.049. Epub 2016 Mar 28.
The actual consequence of suboptimal anticoagulation management in patients with nonvalvular atrial fibrillation (NVAF) is unclear in the real-life practice.
The purpose of this study was to identify the prevalence of suboptimally anticoagulated patients with NVAF and compare the effectiveness and safety of antiplatelet drugs with warfarin.
We performed a retrospective cohort study using a population-wide database managed by the Hong Kong Hospital Authority. Patients newly diagnosed with NVAF during 2010-2013 were included in the analysis. A Cox proportional hazards regression model with 1:1 propensity score matching was used to compare the risk of ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between patients receiving antiplatelet drugs and those receiving warfarin stratified by level of international normalized ratio (INR) control.
Of the 35,551 patients with NVAF, 30,294 (85.2%) had a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes mellitus, age 65-74 years, prior stroke/transient ischemic attack [doubled], vascular disease, and sex category [female]) score of ≥2 (target group for anticoagulation). Of these, 7029 (23.2%) received oral anticoagulants and 18,508 (61.1%) received antiplatelet drugs alone. There were 1541 (67.7%) of warfarin users who had poor INR control (time in therapeutic range [2.0-3.0] <60%). Patients receiving warfarin had comparable risks of intracranial hemorrhage (hazard ratio [HR] 1.24; 95% confidence interval [CI] 0.65-2.34) and gastrointestinal bleeding (HR 1.23; 95% CI 0.84-1.81) and lower risk of ischemic stroke (HR 0.40; 95% CI 0.28-0.57) and all-cause mortality (HR 0.45; 95% CI 0.36-0.57) than did patients receiving antiplatelet drugs alone. Good INR control was associated with a reduced risk of ischemic stroke (HR 0.48; 95% CI 0.27-0.86) as compared with poor INR control. Modeling analyses suggested that ~40,000 stroke cases could be potentially prevented per year in the Chinese population if patients were optimally treated.
More than three-quarters of high-risk patients among this Chinese population with NVAF were not anticoagulated or had poor INR control. There is an urgent need to improve the optimization of anticoagulation for stroke prevention in patients with atrial fibrillation.
在现实生活实践中，非瓣膜性心房颤动（NVAF）患者抗凝管理欠佳的实际后果尚不清楚。
本研究旨在确定抗凝治疗欠佳的NVAF患者的患病率，并比较抗血小板药物与华法林的有效性和安全性。
我们使用香港医院管理局管理的全人群数据库进行了一项回顾性队列研究。纳入2010 - 2013年新诊断为NVAF的患者进行分析。采用Cox比例风险回归模型和1:1倾向评分匹配，比较接受抗血小板药物和接受华法林治疗的患者在国际标准化比值（INR）控制水平分层下发生缺血性卒中、颅内出血、胃肠道出血和全因死亡的风险。
在35551例NVAF患者中，30294例（85.2%）的CHA2DS2 - VASc（充血性心力衰竭、高血压、年龄≥75岁[加倍]、糖尿病、年龄65 - 74岁、既往卒中/短暂性脑缺血发作[加倍]、血管疾病和性别类别[女性]）评分≥2（抗凝治疗目标人群）。其中，7029例（23.2%）接受口服抗凝药治疗，18508例（61.1%）仅接受抗血小板药物治疗。华法林使用者中有1541例（67.7%）的INR控制不佳（治疗范围内时间[2.0 - 3.0]<60%）。接受华法林治疗的患者发生颅内出血（风险比[HR]1.24；95%置信区间[CI]0.65 - 2.34）和胃肠道出血（HR 1.23；95%CI 0.84 - 1.81）的风险相当，而发生缺血性卒中（HR 0.40；95%CI 0.28 - 0.57）和全因死亡（HR 0.45；95%CI 0.36 - 0.57）的风险低于仅接受抗血小板药物治疗的患者。与INR控制不佳相比，良好的INR控制与缺血性卒中风险降低相关（HR 0.48；95%CI 0.27 - 0.86）。模型分析表明，如果对患者进行最佳治疗，中国人群每年可能预防约40000例卒中病例。
在这一中国NVAF人群中，超过四分之三的高危患者未接受抗凝治疗或INR控制不佳。迫切需要改善心房颤动患者预防卒中的抗凝优化治疗。
