Gamble David T, Buono Romain, Mamas Mamas A, Leslie Stephen, Bettencourt-Silva Joao H, Clark Allan B, Bowles Kristian M, Metcalf Anthony K, Potter John F, Myint Phyo K
Ageing Clinical and Experimental Research (ACER) Team, University of Aberdeen, UK.
Keele Cardiovascular Research Group, University of Keele, UK.
Eur J Prev Cardiol. 2020 May;27(7):729-737. doi: 10.1177/2047487319871709. Epub 2019 Sep 3.
Whilst antithrombotic therapy is recommended in people with atrial fibrillation, little is known about the survival benefits of antithrombotic treatment in those with both high ischaemic and bleeding risk scores. We aim to describe the distribution of these risk scores in those with a prior diagnosis of atrial fibrillation who have suffered stroke and to determine the net clinical benefit of antithrombotic treatment.
We used regional stroke register data in the UK. Patients with a prior diagnosis of atrial fibrillation and ischaemic or haemorrhagic stroke patients were selected and their ischaemic stroke risk score (CHADS-VAS) and bleeding risk score (HEMORRHAGES) scores retrospectively calculated. Logistic regression and Cox proportional hazards models were constructed to determine the association between antithrombotic therapy prior to stroke and in-hospital and long-term mortality.
A total of 1928 stroke patients (mean age 81.3 years (standard deviation 8.5), 56.8% women) with prior atrial fibrillation were included. Of these, 1761 (91.3%) suffered ischaemic stroke. The most common phenotype (64%) was of those with both high CHADS-VAS (≥2) and high HEMORRHAGES score (≥4). In our fully adjusted model, patients on antithrombotic treatment with both high ischaemic and bleeding risk had a significant reduction in odds of 31% for in-hospital mortality (odds ratio 0.69 (95% confidence interval 0.48-1.00: = 0.049)) and 17% relative risk reduction for long-term mortality (hazard ratio 0.83 (95% confidence interval 0.71-0.97: = 0.02)).
Our study suggests that antithrombotic treatment has a prognostic benefit following incident stroke in those with both high ischaemic risk and high bleeding risk. This should be considered when choosing treatment options in this group of patients.
虽然心房颤动患者推荐使用抗血栓治疗，但对于缺血风险和出血风险评分均高的患者，抗血栓治疗对生存的益处知之甚少。我们旨在描述既往诊断为心房颤动且发生过卒中的患者中这些风险评分的分布情况，并确定抗血栓治疗的净临床获益。
我们使用了英国的区域卒中登记数据。选择既往诊断为心房颤动的缺血性或出血性卒中患者，并回顾性计算他们的缺血性卒中风险评分（CHADS-VAS）和出血风险评分（HEMORRHAGES）。构建逻辑回归和Cox比例风险模型，以确定卒中前抗血栓治疗与住院期间及长期死亡率之间的关联。
共纳入1928例既往有房颤的卒中患者（平均年龄81.3岁（标准差8.5），56.8%为女性）。其中，1761例（91.3%）发生缺血性卒中。最常见的表型（64%）是CHADS-VAS评分高（≥2）且HEMORRHAGES评分高（≥4）的患者。在我们的完全调整模型中，缺血和出血风险均高且接受抗血栓治疗的患者住院死亡率的优势比显著降低31%（优势比0.69（95%置信区间0.48-1.00：P = 0.049）），长期死亡率的相对风险降低17%（风险比0.83（95%置信区间0.71-0.97：P = 0.02））。
我们的研究表明，抗血栓治疗对缺血风险高和出血风险高的患者发生卒中后具有预后益处。在为这组患者选择治疗方案时应考虑这一点。
