Mentel Antonia, Quinn Terence J, Cameron Alan C, Lees Kennedy R, Abdul-Rahim Azmil H
School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
Eur Stroke J. 2020 Jun;5(2):155-168. doi: 10.1177/2396987319896674. Epub 2020 Jan 13.
There is conflicting evidence on the impact of atrial fibrillation (AF) type, i.e. non-paroxysmal AF or paroxysmal AF, on thromboembolic recurrence. The consensus of risk equivalence is greatly based on historical evidence, focussing on initial stroke risks. We conducted a systematic review and meta-analysis to describe the impact of AF type on the risk of thromboembolic recurrence, mortality and major haemorrhage in patients with previous stroke.
We systematically searched four multidisciplinary databases from inception to December 2018. We selected observational studies investigating clinical outcomes in patients with ischaemic stroke and AF, stratified by AF type. We assessed all included studies for risk of bias using the 'Risk of Bias In Non-randomised Studies - of Exposures' tool. The Comprehensive Meta-Analysis Software was used to calculate odds ratios from crude event rates.
After reviewing 14,127 citations, we selected 108 studies for full-text screening. We extracted data from a total of 26 studies, reporting outcomes on 23,054 patients. Overall, risk of bias was moderate. The annual incidence rates of thromboembolism in patients with non-paroxysmal AF and paroxysmal AF were 7.1% (95% confidence interval: 4.2-11.7) and 5.2% (95% confidence interval: 3.2-8.2), respectively. The odds ratio for thromboembolism in patients with non-paroxysmal AF versus paroxysmal AF was 1.47 (95% confidence interval: 1.08-1.99, = 0.013). The annual mortality rates in patients with non-paroxysmal AF and paroxysmal AF were 20.0% (95% confidence interval: 13.2-28.0) and 10.1% (95% confidence interval: 5.4-17.3), respectively, and odds ratio was 1.90 (95% confidence interval: 1.43-2.52, < 0.001). There was no difference in rates of major haemorrhage, odds ratio = 1.01 (95% confidence interval: 0.61-1.69, = 0.966).
In patients with prior stroke, non-paroxysmal AF is associated with significantly higher risk of thromboembolic recurrence and mortality than paroxysmal AF. Although current guidelines make no distinction between non-paroxysmal AF and paroxysmal AF for secondary stroke prevention, future guidance and risk stratification tools may need to consider this differential risk (PROSPERO ID: CRD42019118531).
关于房颤类型（即非阵发性房颤或阵发性房颤）对血栓栓塞复发的影响，证据存在冲突。风险等效性的共识很大程度上基于历史证据，重点关注初始卒中风险。我们进行了一项系统评价和荟萃分析，以描述房颤类型对既往卒中患者血栓栓塞复发风险、死亡率和大出血的影响。
我们从数据库建立至2018年12月对四个多学科数据库进行了系统检索。我们选择了按房颤类型分层的、调查缺血性卒中和房颤患者临床结局的观察性研究。我们使用“非随机研究中的暴露偏倚风险”工具评估所有纳入研究的偏倚风险。使用综合荟萃分析软件从原始事件率计算比值比。
在查阅14,127篇文献后，我们选择了108项研究进行全文筛选。我们从总共26项研究中提取了数据，报告了23,054例患者的结局。总体而言，偏倚风险为中度。非阵发性房颤和阵发性房颤患者的血栓栓塞年发病率分别为7.1%（95%置信区间：4.2 - 11.7）和5.2%（95%置信区间：3.2 - 8.2）。非阵发性房颤患者与阵发性房颤患者相比，血栓栓塞的比值比为1.47（95%置信区间：1.08 - 1.99，P = 0.013）。非阵发性房颤和阵发性房颤患者的年死亡率分别为20.0%（95%置信区间：13.2 - 28.0）和10.1%（95%置信区间：5.4 - 17.3），比值比为1.90（95%置信区间：1.43 - 2.52，P < 0.001）。大出血发生率无差异，比值比 = 1.01（95%置信区间：0.61 - 1.69，P = 0.966）。
在既往卒中患者中，非阵发性房颤与血栓栓塞复发和死亡风险显著高于阵发性房颤相关。尽管当前指南在二级卒中预防中未区分非阵发性房颤和阵发性房颤，但未来指南和风险分层工具可能需要考虑这种风险差异（国际前瞻性系统评价注册编号：CRD42019118531）。
