Mironova Staroverova A I, Panchenko E P, Kropacheva E S, Zemlyanskaya O A
Myasnikov Institute of Clinical Cardiology, National Medical Research Center for Cardiology.
Ter Arkh. 2020 Oct 14;92(9):15-23. doi: 10.26442/00403660.2020.09.000655.
To analyze the frequency of resumption of anticoagulant therapy (ACT) after major and clinically significant bleeding among AF patients who received oral anticoagulants and were observed in the Department of clinical problems of atherothrombosis from 1999 to 2019 within the retro-prospective register Regata-2, and to search for clinical factors associated with recurrence of hemorrhagic complications among patients who resumed anticoagulant therapy after a bleeding episode.
In cohort study of patients with high-risk AF with absolute indications for ACT we enrolled 290 AF patients (130 women and 160 men) aged 32 to 85 years (the average age was 65.188.89 years). During the follow-up period, 92 patients developed hemorrhagic complications, and 73 of them resumed ACT. 35 of the 73 patients who resumed ACT developed a relapse of major/clinically significant bleeding.
The frequency of resuming ACT after the first hemorrhagic complication increased over time from 75% in the period from 19992003 to 90% in the period 20152019. We were not able to establish an exact relationship between the presence of concomitant pathology and the decision to resume the ACT after bleeding. The only reliable reason for refusing to resume the ACT was the patients categorical reluctance. Among patients who had recurrent hemorrhagic complications, the total score on the Charleson comorbidity scale was significantly higher (4.232.01vs3.521.43;p=0.0425). Patients with recurrent bleeding were significantly more likely to suffer from CKD with a decrease in GFR less than 60 ml/min/1.73 sq. m, and also had a history of erosive and ulcerative lesions of the gastrointestinal tract. There was also a significant Association of recurrent bleeding with the use of proton pump inhibitors. Subgroups of patients who switched from warfarin to taking direct oral anticoagulants after the first bleeding and subsequent recurrent bleeding did not differ in basic clinical characteristics from patients without bleeding after changing the anticoagulant. According to multiple regression analysis, NSAIDs showed a tendency to develop a relapse of B/C bleeding on the background of direct oral anticoagulants in patients who underwent GO on the background of warfarin therapy (b=0.4524,p=0.0530).
During the 20-year follow-up, the frequency of all major and clinically significant bleeding was 2.6/100 patients-years, the frequency of first bleeding was 5.86/100 patients-years, while the frequency of repeated hemorrhagic complications was 7.06/100 patients-years. Patients with a high thromboembolic risk should receive anticoagulants, provided that the modifiable risk factors for bleeding are carefully corrected.
分析1999年至2019年在回顾性前瞻性登记册Regata - 2中接受口服抗凝剂治疗并在动脉粥样硬化血栓形成临床问题科接受观察的房颤患者发生大出血和具有临床意义的出血后恢复抗凝治疗（ACT）的频率，并寻找出血事件后恢复抗凝治疗的患者中与出血并发症复发相关的临床因素。
在一项针对有ACT绝对指征的高危房颤患者的队列研究中，我们纳入了290例年龄在32至85岁（平均年龄为65.1±8.89岁）的房颤患者（130名女性和160名男性）。在随访期间，92例患者出现出血并发症，其中73例恢复了ACT。恢复ACT的73例患者中有35例发生了大出血/具有临床意义的出血复发。
首次出血并发症后恢复ACT的频率随时间增加，从1999 - 2003年期间的75%增至2015 - 2019年期间的90%。我们未能确定合并症的存在与出血后恢复ACT的决定之间的确切关系。拒绝恢复ACT的唯一可靠原因是患者明确表示不愿意。在有复发性出血并发症的患者中，Charlson合并症量表的总分显著更高（4.23±2.01 vs 3.52±1.43；p = 0.0425）。复发性出血患者更易患估算肾小球滤过率（GFR）低于60 ml/min/1.73平方米的慢性肾脏病（CKD），并且有胃肠道糜烂和溃疡性病变史。复发性出血还与使用质子泵抑制剂显著相关。首次出血后从华法林转换为服用直接口服抗凝剂以及随后复发性出血的患者亚组，在更换抗凝剂后与无出血患者的基本临床特征无差异。根据多元回归分析，在华法林治疗背景下接受胃肠镜检查（GO）的患者中，非甾体抗炎药（NSAIDs）在直接口服抗凝剂背景下有发生B/C级出血复发的趋势（b = 0.4524，p = 0.0530）。
在20年的随访中，所有大出血和具有临床意义的出血频率为2.6/100患者 - 年，首次出血频率为5.86/100患者 - 年，而复发性出血并发症频率为7.06/100患者 - 年。具有高血栓栓塞风险的患者应接受抗凝治疗，前提是仔细纠正可改变的出血危险因素。
