Yoon Chang-Yun, Noh Juhwan, Jhee Jong Hyun, Chang Tae Ik, Kang Ea Wha, Kee Youn Kyung, Kim Hyoungnae, Park Seohyun, Yun Hae-Ryong, Jung Su-Young, Oh Hyung Jung, Park Jung Tak, Han Seung Hyeok, Kang Shin-Wook, Kim Changsoo, Yoo Tae-Hyun
From the Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea (C.-Y.Y., J.H.J., Y.K.K., H.K., S.P., H.-R.Y., S.-Y.J., J.T.P., S.H.H., S.-W.K., T.-H.Y.); Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (J.N., C.K.); Division of Nephrology, Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea (T.I.C., E.W.K.); and Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea (H.J.O.).
Stroke. 2017 Sep;48(9):2472-2479. doi: 10.1161/STROKEAHA.117.017114. Epub 2017 Aug 11.
The aim of this study is to elucidate the effects of warfarin use in patients with atrial fibrillation undergoing dialysis using a population-based Korean registry.
Data were extracted from the Health Insurance Review and Assessment Service, which is a nationwide, mandatory social insurance database of all Korean citizens enrolled in the National Health Information Service between 2009 and 2013. Thromboembolic and hemorrhagic outcomes were analyzed according to warfarin use. Overall and propensity score-matched cohorts were analyzed by Cox proportional hazards models.
Among 9974 hemodialysis patients with atrial fibrillation, the mean age was 66.6±12.2 years, 5806 (58.2%) were men, and 2921 (29.3%) used warfarin. After propensity score matching to adjust for all described baseline differences, 5548 subjects remained, and differences in baseline variables were distributed equally between warfarin users and nonusers. During a mean follow-up duration of 15.9±11.1 months, ischemic and hemorrhagic stroke occurred in 678 (6.8%) and 227 (2.3%) patients, respectively. In a multiple Cox model, warfarin use was significantly associated with an increased risk of hemorrhagic stroke (hazard ratio, 1.44; 95% confidence interval, 1.09-1.91; =0.010) in the overall cohort. Furthermore, a significant relationship between warfarin use and hemorrhagic stroke was found in propensity-matched subjects (hazard ratio, 1.56; 95% confidence interval, 1.10-2.22; =0.013). However, the ratios for ischemic stroke were not significantly different in either the propensity-matched (hazard ratio, 0.95; 95% confidence interval, 0.78-1.15; =0.569) or overall cohort (hazard ratio, 1.06; 95% confidence interval, 0.90-1.26; =0.470).
Our findings suggest that warfarin should be used carefully in hemodialysis patients, given the higher risk of hemorrhagic events and the lack of ability to prevent thromboembolic complications.
本研究旨在利用韩国一项基于人群的登记系统，阐明华法林在接受透析的房颤患者中的应用效果。
数据取自健康保险审查与评估服务机构，该机构是一个覆盖全国的强制性社会保险数据库，涵盖了2009年至2013年期间加入国家健康信息服务的所有韩国公民。根据华法林的使用情况分析血栓栓塞和出血结局。通过Cox比例风险模型分析总体队列和倾向评分匹配队列。
在9974例患有房颤的血液透析患者中，平均年龄为66.6±12.2岁，5806例（58.2%）为男性，2921例（29.3%）使用华法林。在进行倾向评分匹配以调整所有所述基线差异后，剩余5548名受试者，基线变量差异在华法林使用者和非使用者之间平均分布。在平均随访15.9±11.1个月期间，分别有678例（6.8%）和227例（2.3%）患者发生缺血性和出血性卒中。在多因素Cox模型中，在总体队列中，使用华法林与出血性卒中风险增加显著相关（风险比，1.44；95%置信区间，1.09 - 1.91；P = 0.010）。此外，在倾向评分匹配的受试者中发现华法林使用与出血性卒中之间存在显著关系（风险比，1.56；95%置信区间，1.10 - 2.22；P = 0.013）。然而，在倾向评分匹配队列（风险比，0.95；95%置信区间，0.78 - 1.15；P = 0.569）或总体队列（风险比，1.06；95%置信区间，0.90 - 1.26；P = 0.470）中，缺血性卒中的比例均无显著差异。
我们的研究结果表明，鉴于出血事件风险较高且无法预防血栓栓塞并发症，在血液透析患者中应谨慎使用华法林。
