From the University of Birmingham Institute for Cardiovascular Sciences, City Hospital, United Kingdom (M.M., E.S., D.A.L., M.P., G.Y.H.L.); Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland (M.M.); and Division of Family Practice, Chilliwack General Hospital, British Columbia, Canada (A.W.).
Stroke. 2017 Aug;48(8):2198-2205. doi: 10.1161/STROKEAHA.116.016146. Epub 2017 Jul 5.
Although patients with atrial fibrillation (AF) who experienced an acute stroke are at high risk for recurrence, many patients are untreated or treated suboptimally for stroke prevention. The objective of this study is to compare clinical outcomes of AF patients with versus without previous stroke in relation to guideline-adherent antithrombotic treatment in a contemporary primary care population.
Community cohort of 105 000 patients from 11 general practices in Darlington, England, was used to assess AF stroke prevention strategies against 2014 National Institute for Health and Care Excellence guidelines.
Overall, 2259 (2.15%) patients with AF were identified, of which 18.9% constituted a secondary prevention cohort. For secondary prevention, antithrombotic treatment was guideline adherent in 56.3%, 18.9% were overtreated, and 24.8% undertreated; corresponding proportions for primary prevention were 49.5%, 11.7%, and 38.8%, respectively. One-year stroke rates were 8.6% and 1.6% for secondary and primary prevention, respectively (<0.001); corresponding all-cause mortality rates were 9.8% and 9.4%, respectively (=0.79). On multivariable analysis, lack of antithrombotic treatment guideline adherence was associated with increased stroke risk for primary prevention (odds ratio, 2.95; 95% confidence interval, 1.26-6.90; =0.013 for undertreatment); for secondary prevention, lack of guideline adherence was associated with increased risk of recurrent stroke (odds ratio, 2.80; 95% confidence interval, 1.25-6.27; =0.012 for overtreatment) and all-cause death (odds ratio, 2.75; 95% confidence interval, 1.33-5.69; =0.006 for undertreatment).
Only approximately half of eligible patients with AF are prescribed oral anticoagulation in line with guidelines. Guideline-adherent antithrombotic treatment significantly reduces the risk of stroke among primary prevention patients and both risk of recurrent stroke and death in patients with previous stroke.
尽管患有心房颤动（AF）并经历过急性中风的患者再次中风的风险很高，但许多患者未接受或未接受最佳的中风预防治疗。本研究的目的是比较有/无既往中风的 AF 患者在当代初级保健人群中接受符合指南的抗血栓治疗的临床结局。
使用来自英国达灵顿的 11 家全科诊所的 105000 名患者的社区队列，评估 AF 中风预防策略是否符合 2014 年国家卫生与保健卓越研究所指南。
总体而言，确定了 2259 名（2.15%）患有 AF 的患者，其中 18.9%构成二级预防队列。对于二级预防，抗血栓治疗符合指南的比例为 56.3%，过度治疗的比例为 18.9%，治疗不足的比例为 24.8%；一级预防的相应比例分别为 49.5%、11.7%和 38.8%。二级预防和一级预防的 1 年中风发生率分别为 8.6%和 1.6%（<0.001）；相应的全因死亡率分别为 9.8%和 9.4%（=0.79）。多变量分析显示，缺乏抗血栓治疗指南的遵循与一级预防的中风风险增加相关（比值比，2.95；95%置信区间，1.26-6.90；=0.013 用于治疗不足）；对于二级预防，缺乏指南遵循与复发性中风（比值比，2.80；95%置信区间，1.25-6.27；=0.012 用于过度治疗）和全因死亡（比值比，2.75；95%置信区间，1.33-5.69；=0.006 用于治疗不足）的风险增加相关。
仅有大约一半符合条件的 AF 患者按照指南开出处方抗凝药。符合指南的抗血栓治疗可显著降低一级预防患者中风风险，并降低既往中风患者再次中风和死亡的风险。
