Peacock W Frank, Tamayo Sally, Patel Manesh, Sicignano Nicholas, Hopf Kathleen P, Yuan Zhong
Department of Emergency Medicine, Baylor College of Medicine, Houston, TX.
Department of Cardiology, Marine Corps, United States Navy, Naval Medical Center, Portsmouth, VA.
Ann Emerg Med. 2017 May;69(5):541-550.e1. doi: 10.1016/j.annemergmed.2016.09.032. Epub 2016 Nov 29.
Assessing stroke risk associated with nonvalvular atrial fibrillation depends on the evaluation of patient characteristics and clinical features. Clinicians must determine that the net clinical benefit from anticoagulation therapy outweighs its risk, namely, bleeding. Risk assessment for stroke is commonly performed by calculating a CHADS-VASc (congestive heart failure/left ventricular dysfunction, hypertension, ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack or thromboembolism, vascular disease, aged 65 to 74 years, sex female) score. It is possible that CHADS-VASc scores also have a relationship with the incidence of major bleeding. We examined the relationship between CHADS-VASc scores and major bleeding in rivaroxaban users with nonvalvular atrial fibrillation.
Electronic medical records of more than 10 million patients from the Department of Defense Military Health System were queried to identify patients with nonvalvular atrial fibrillation who received rivaroxaban from January 1, 2013, to June 30, 2015. Baseline characteristics of the study population were described by CHADS-VASc scores and major bleeding status; major bleeding incidence was evaluated by CHADS-VASc score category and for each CHADS-VASc component.
Overall, 44,793 patients met the inclusion criteria for this analysis. The major bleeding incidence rate was 2.84 (95% confidence interval 2.69 to 3.00) per 100 person-years. The incidence of major bleeding increased from 0.30 to 5.40 per 100 person-years among patients with a CHADS-VASc score of 0 to 5 or higher, respectively. Fatal outcomes among patients with major bleeding were positively correlated with CHADS-VASc scores; patients with higher scores had higher mortality rates. The CHADS-VASc component with the highest major bleeding incidence was for vascular disease, 5.69 (95% confidence interval 5.18 to 6.24) per 100 person-years.
Higher CHADS-VASc scores are associated with increased incidence of major bleeding in nonvalvular atrial fibrillation patients receiving rivaroxaban.
评估与非瓣膜性心房颤动相关的卒中风险取决于对患者特征和临床特征的评估。临床医生必须确定抗凝治疗的净临床获益大于其风险，即出血风险。卒中风险评估通常通过计算CHADS-VASc（充血性心力衰竭/左心室功能障碍、高血压、≥75岁、糖尿病、既往卒中或短暂性脑缺血发作或血栓栓塞、血管疾病、65至74岁、女性）评分来进行。CHADS-VASc评分也有可能与大出血的发生率相关。我们研究了非瓣膜性心房颤动患者使用利伐沙班时CHADS-VASc评分与大出血之间的关系。
查询美国国防部军事卫生系统超过1000万患者的电子病历，以识别2013年1月1日至2015年6月30日期间接受利伐沙班治疗的非瓣膜性心房颤动患者。通过CHADS-VASc评分和大出血状态描述研究人群的基线特征；通过CHADS-VASc评分类别和每个CHADS-VASc组成部分评估大出血发生率。
总体而言，44793名患者符合本分析的纳入标准。大出血发生率为每100人年2.84例（95%置信区间2.69至3.00）。CHADS-VASc评分为0至5分或更高的患者中，大出血发生率分别从每100人年0.30例增加到5.40例。大出血患者的死亡结局与CHADS-VASc评分呈正相关；评分较高的患者死亡率较高。大出血发生率最高的CHADS-VASc组成部分是血管疾病，每100人年5.69例（95%置信区间5.18至6.24）。
在接受利伐沙班治疗的非瓣膜性心房颤动患者中，较高的CHADS-VASc评分与大出血发生率增加相关。
