Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom; Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.
Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Heart Rhythm. 2020 Jan;17(1):33-40. doi: 10.1016/j.hrthm.2019.07.034. Epub 2019 Aug 1.
Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel is used for stroke prevention in patients with atrial fibrillation (AF) who refuse to take use oral anticoagulants (OACs). However, clinical data comparing these treatments are limited.
The purpose of this study was to compare the clinical outcomes between DAPT and OAC in patients with AF.
A cohort study using a population-wide database of the Hong Kong Hospital Authority was performed. New patients with AF from 2010-2014 who were prescribed DAPT or OAC (warfarin or dabigatran) were followed until July 31, 2016. Outcomes were thromboembolism, bleeding, and death. Propensity score (PS) matching at a ratio of 1:2 was used to select DAPT users with characteristics similar to those of OAC users, analyzed using Poisson regression.
Among 51,946 new patients with AF, 8520 users of OAC and DAPT were identified. The likelihood of receiving DAPT over OAC increased with older age and previous intracranial hemorrhage. Among DAPT users, the incidences of thromboembolism, death, and bleeding per 100 patient-years were 15.8, 17.6, and 5.1, respectively. Compared to DAPT users, PS-matched analysis indicated a lower incidence of thromboembolism and/or death among OAC users (dabigatran: incidence rate ratio [IRR] 0.32; 95% confidence interval [CI] 0.19-0.55; warfarin: IRR 0.58; 95% CI 0.36-0.95), with no significant differences in bleeding events.
DAPT users were at markedly increased risk for thromboembolism and death compared to OAC users. These findings indicate the need for improved stroke risk reduction strategies among patients taking DAPT and the opportunities for using OAC in high-risk groups to prevent additional events.
对于拒绝使用口服抗凝剂（OAC）的房颤（AF）患者，采用阿司匹林联合氯吡格雷的双联抗血小板治疗（DAPT）用于预防中风。然而，比较这些治疗方法的临床数据有限。
本研究旨在比较 AF 患者中 DAPT 和 OAC 的临床结局。
采用香港医院管理局全人群数据库进行队列研究。对 2010-2014 年新诊断为 AF 并接受 DAPT（阿司匹林+氯吡格雷）或 OAC（华法林或达比加群）治疗的患者进行随访，直至 2016 年 7 月 31 日。结局为血栓栓塞、出血和死亡。采用倾向性评分（PS）1:2 匹配选择 DAPT 使用者与 OAC 使用者特征相似的患者，采用泊松回归进行分析。
在 51946 例新发 AF 患者中，共确定 8520 例 OAC 和 DAPT 使用者。接受 DAPT 的可能性随着年龄增长和既往颅内出血而增加。在 DAPT 使用者中，每 100 患者年的血栓栓塞、死亡和出血发生率分别为 15.8、17.6 和 5.1。与 DAPT 使用者相比，PS 匹配分析显示 OAC 使用者的血栓栓塞和/或死亡发生率较低（达比加群：发生率比[IRR]0.32；95%置信区间[CI]0.19-0.55；华法林：IRR 0.58；95%CI 0.36-0.95），出血事件无显著差异。
与 OAC 使用者相比，DAPT 使用者发生血栓栓塞和死亡的风险显著增加。这些发现表明，需要为接受 DAPT 的患者制定更好的降低中风风险策略，并为高危人群使用 OAC 预防额外事件提供机会。
