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遵循抗血栓治疗指南可改善老年房颤患者的死亡率:来自REPOSI研究的见解。

Adherence to antithrombotic therapy guidelines improves mortality among elderly patients with atrial fibrillation: insights from the REPOSI study.

作者信息

Proietti Marco, Nobili Alessandro, Raparelli Valeria, Napoleone Laura, Mannucci Pier Mannuccio, Lip Gregory Y H

机构信息

Institute of Cardiovascular Sciences, City Hospital, University of Birmingham, Birmingham, Dudley Road, B18 7QH, UK.

Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy.

出版信息

Clin Res Cardiol. 2016 Nov;105(11):912-920. doi: 10.1007/s00392-016-0999-4. Epub 2016 May 31.

Abstract

BACKGROUND

Atrial fibrillation (AF) is associated with a substantial risk of thromboembolism and mortality, significantly reduced by oral anticoagulation. Adherence to guidelines may lower the risks for both all cause and cardiovascular (CV) deaths.

METHODS

Our objective was to evaluate if antithrombotic prophylaxis according to the 2012 European Society of Cardiology (ESC) guidelines is associated to a lower rate of adverse outcomes. Data were obtained from REPOSI; a prospective observational study enrolling inpatients aged ≥65 years. Patients enrolled in 2012 and 2014 discharged with an AF diagnosis were analysed.

RESULTS

Among 2535 patients, 558 (22.0 %) were discharged with a diagnosis of AF. Based on ESC guidelines, 40.9 % of patients were on guideline-adherent thromboprophylaxis, 6.8 % were overtreated, and 52.3 % were undertreated. Logistic analysis showed that increasing age (p = 0.01), heart failure (p = 0.04), coronary artery disease (p = 0.013), peripheral arterial disease (p = 0.03) and concomitant cancer (p = 0.003) were associated with non-adherence to guidelines. Specifically, undertreatment was significantly associated with increasing age (p = 0.001) and cancer (p < 0.001), and inversely associated with HF (p = 0.023). AF patients who were guideline adherent had a lower rate of both all-cause death (p = 0.007) and CV death (p = 0.024) compared to those non-adherent. Kaplan-Meier analysis showed that guideline-adherent patients had a lower cumulative risk for both all-cause (p = 0.002) and CV deaths (p = 0.011). On Cox regression analysis, guideline adherence was independently associated with a lower risk of all-cause and CV deaths (p = 0.019 and p = 0.006).

CONCLUSIONS

Non-adherence to guidelines is highly prevalent among elderly AF patients, despite guideline-adherent treatment being independently associated with lower risk of all-cause and CV deaths. Efforts to improve guideline adherence would lead to better outcomes for elderly AF patients.

摘要

背景

心房颤动(AF)与血栓栓塞和死亡的重大风险相关,口服抗凝治疗可显著降低该风险。遵循指南可能会降低全因死亡和心血管(CV)死亡的风险。

方法

我们的目的是评估根据2012年欧洲心脏病学会(ESC)指南进行的抗血栓预防是否与较低的不良结局发生率相关。数据来自REPOSI;一项纳入年龄≥65岁住院患者的前瞻性观察性研究。对2012年和2014年出院时诊断为AF的患者进行分析。

结果

在2535例患者中,558例(22.0%)出院时诊断为AF。根据ESC指南,40.9%的患者接受了符合指南的血栓预防治疗,6.8%的患者治疗过度,52.3%的患者治疗不足。逻辑分析显示,年龄增加(p = 0.01)、心力衰竭(p = 0.04)、冠状动脉疾病(p = 0.013)、外周动脉疾病(p = 0.03)和合并癌症(p = 0.003)与不遵循指南相关。具体而言,治疗不足与年龄增加(p = 0.001)和癌症(p < 0.001)显著相关,与心力衰竭呈负相关(p = 0.023)。与未遵循指南的AF患者相比,遵循指南的AF患者全因死亡(p = 0.007)和CV死亡(p = 0.024)发生率均较低。Kaplan-Meier分析显示,遵循指南的患者全因死亡(p = 0.002)和CV死亡(p = 0.011)的累积风险均较低。在Cox回归分析中,遵循指南与较低的全因死亡和CV死亡风险独立相关(p = 0.019和p = 0.006)。

结论

尽管遵循指南的治疗与较低的全因死亡和CV死亡风险独立相关,但老年AF患者中不遵循指南的情况非常普遍。努力提高指南遵循率将为老年AF患者带来更好的结局。

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