Ehrlinder Hanne, Orsini Nicola, Modig Karin, Hofman-Bang Claes, Wallén Håkan, Gigante Bruna
Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
Int J Cardiol Heart Vasc. 2020 Mar 30;27:100505. doi: 10.1016/j.ijcha.2020.100505. eCollection 2020 Apr.
Antithrombotic treatment represents a dilemma in elderly patients with atrial fibrillation since both risk of thromboembolism and bleeding are age-dependent complications. A paradigm shift occurred over the past 10 years when aspirin was overcome by warfarin and further by the direct oral anticoagulants. Here we present a clinical practice-based analysis of a cohort of elderly inpatient atrial fibrillation patients and investigate the influence of clinical factors in the choice of antithrombotic strategy.
Study participants (n = 2943) are consecutive patients aged 75-104 years discharged from a Swedish university hospital with atrial fibrillation or atrial flutter as main diagnosis between November 1st 2010 and December 31st 2017. Cardiovascular risk factors, comorbidities and antithrombotic treatment at discharge were manually extracted from medical charts. A logistic regression analysis was performed to estimate predictors of the probability to receive direct oral anticoagulants (DOACs) compared to warfarin.
Patients aged ≥90 y (n = 446, women 73%) showed the highest prevalence of cardiovascular comorbidities and the highest bleeding and thromboembolic risk. DOACs became more commonly prescribed than warfarin in 2016/2017 across all ages. However, the probability to receive DOAC as compared to warfarin was lower in the presence of high bleeding risk (OR 0,55; 95% CI 0,40-0,77; p = 0,00) and high thromboembolic risk (OR 0,74; 95% CI 0,59-0,94; p = 0,01).
Elderly atrial fibrillation patients represent a heterogenous group where the oldest (≥90 years) show both a very high thromboembolic and bleeding risk profile. In the presence of high thromboembolic and bleeding risk, warfarin was still preferred over DOAC.
抗栓治疗对于老年房颤患者而言是个两难问题，因为血栓栓塞风险和出血都是与年龄相关的并发症。在过去10年里出现了一种范式转变，先是华法林取代了阿司匹林，随后直接口服抗凝剂又取代了华法林。在此，我们基于临床实践对一组老年住院房颤患者进行分析，并研究临床因素在抗栓策略选择中的影响。
研究参与者（n = 2943）为2010年11月1日至2017年12月31日期间从瑞典一家大学医院出院的75至104岁连续患者，主要诊断为房颤或房扑。从病历中手动提取心血管危险因素、合并症及出院时的抗栓治疗情况。进行逻辑回归分析以估计与华法林相比接受直接口服抗凝剂（DOACs）概率的预测因素。
≥90岁的患者（n = 446，女性占73%）心血管合并症患病率最高，出血和血栓栓塞风险也最高。在所有年龄段中，2016/2017年DOACs的处方比华法林更为常见。然而，在出血风险高（比值比0.55；95%置信区间0.40 - 0.77；p = 0.00）和血栓栓塞风险高（比值比0.74；95%置信区间0.59 - 0.94；p = 0.01）的情况下，与华法林相比接受DOAC的概率较低。
老年房颤患者是一个异质性群体，年龄最大的（≥90岁）患者血栓栓塞和出血风险都非常高。在血栓栓塞和出血风险高的情况下，华法林仍比DOAC更受青睐。
