Inova Heart and Vascular Institute, Falls Church, VA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
Am Heart J. 2018 Mar;197:1-8. doi: 10.1016/j.ahj.2017.09.020. Epub 2017 Oct 24.
Patients with prior stroke are at greater risk for recurrent cardiovascular events post-acute coronary syndromes (ACS) and may have a different risk/benefit profile with antithrombotic therapy than patients without prior stroke.
We studied 7391 patients with ACS from APPRAISE-2, stratified by the presence or absence of prior stroke. Baseline characteristics and outcomes of cardiovascular death, myocardial infarction (MI), or stroke were compared between groups. Interactions between prior stroke, treatment assignment (apixaban vs placebo), and outcomes were tested before and after multivariable adjustment with Cox proportional hazards models.
A total of 902 patients (12%) had prior stroke. Those with prior stroke were older (69 vs 67 years), had more hypertension (91% vs 77%), peripheral vascular disease (22% vs18%), and impaired renal function (38% vs 30%) but less diabetes (44% vs 48%) than those without prior stroke. Patients with prior stroke vs no prior stroke had higher unadjusted rates of cardiovascular death (4.8% vs 4.0%), MI (11.2% vs 7.1%), and ischemic stroke (3.2% vs 0.9%). Patients with prior stroke assigned to apixaban had similar rates of the composite of cardiovascular death, MI, or stroke compared with those assigned to placebo (HR 1.39; 95% CI 0.92-2.08). Patients without prior stroke assigned to apixaban had similar rates of cardiovascular death, MI, or ischemic stroke compared with those assigned to placebo (HR 0.87; 95% CI 0.73-1.04; P-interaction=.041). Median follow-up was 240 days.
Patients with prior stroke are at higher risk for recurrent cardiovascular events post-ACS and had a differential risk/benefit profile with oral anticoagulation.
患有既往卒中的患者在急性冠脉综合征（ACS）后发生心血管事件复发的风险更高，并且与无既往卒中的患者相比，其抗血栓治疗的风险/获益情况可能不同。
我们对 APPRAISE-2 研究中的 7391 例 ACS 患者进行了研究，根据是否存在既往卒中进行分层。比较两组之间心血管死亡、心肌梗死（MI）或卒中的基线特征和结局。在多变量调整后，使用 Cox 比例风险模型在调整前和调整后测试既往卒中、治疗分配（阿哌沙班与安慰剂）与结局之间的相互作用。
共有 902 例（12%）患者存在既往卒中。既往卒中患者年龄较大（69 岁 vs 67 岁），高血压（91% vs 77%）、外周血管疾病（22% vs 18%）和肾功能不全（38% vs 30%）更常见，但糖尿病（44% vs 48%）更少。与无既往卒中的患者相比，既往卒中患者的未调整心血管死亡（4.8% vs 4.0%）、MI（11.2% vs 7.1%）和缺血性卒中（3.2% vs 0.9%）发生率更高。与安慰剂相比，既往卒中且接受阿哌沙班治疗的患者复合心血管死亡、MI 或卒中发生率相似（HR 1.39；95%CI 0.92-2.08）。既往卒中且接受安慰剂治疗的患者与无既往卒中且接受安慰剂治疗的患者相比，心血管死亡、MI 或缺血性卒中发生率相似（HR 0.87；95%CI 0.73-1.04；P 交互作用=0.041）。中位随访时间为 240 天。
既往卒中的患者在 ACS 后发生心血管事件复发的风险更高，并且口服抗凝剂的风险/获益情况存在差异。
