Holbrook Anne, Benipal Harsukh, Paterson J Michael, Martins Diana, Greaves Simon, Lee Munil, Gomes Tara
Division of Clinical Pharmacology & Toxicology (Holbrook), Department of Medicine and Department of Health Research Methods, Evidence, and Impact (Holbrook, Benipal, Greaves), McMaster University, Hamilton, Ont.; ICES (Paterson, Gomes); Institute of Health Policy, Management and Evaluation (Paterson), University of Toronto, Toronto, Ont.; Schulich School of Medicine and Dentistry (Lee), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Martins, Gomes), St. Michael's Hospital, Toronto, Ont.
CMAJ Open. 2021 Apr 16;9(2):E364-E375. doi: 10.9778/cmajo.20200138. Print 2021 Apr-Jun.
Oral anticoagulants are commonly used high-risk medications, but little is known about their safety in transition from hospital to home. Our objective was to measure the rates of hemorrhage and thromboembolic events among older adults receiving oral anticoagulant treatment early after hospital discharge compared to later.
We conducted a retrospective population-based cohort study among Ontario residents aged 66 years or more who started, continued or resumed oral anticoagulant therapy at hospital discharge between September 2010 and March 2015. We calculated the rates of hemorrhage and thromboembolic events requiring hospital admission or an emergency department visit over a 1-year follow-up period, stratified by the first 30 days after discharge and the remainder of the year. We used multivariable regression models, adjusting for covariates, to estimate the effect of sex, prevalent versus incident use, and switching anticoagulants on events.
A total of 123 139 patients (68 408 women [55.6%]; mean age 78.2 yr) were included. About one-quarter (32 563 [26.4%]) had a Charlson Comorbidity Index score of 2 or higher. The rates of hemorrhage and thromboembolic events per 100 person-years were highest during the first 30 days after hospital discharge (25.8, 95% CI 24.8-26.8 and 19.3, 95% CI 18.4-20.2, respectively), falling to 15.7 (95% CI 15.3-16.1) and 6.9 (95% CI 6.6-7.1), respectively, during the subsequent 11 months. Multivariable analysis showed that patients whose anticoagulant was switched in hospital and men had more hemorrhages and thromboembolic events in follow-up.
The first few weeks following hospital discharge represent a very high-risk period for adverse events related to oral anticoagulant treatment among older adults. The results support an intervention trial addressing anticoagulation management in the early postdischarge period.
口服抗凝剂是常用的高风险药物，但对于其在从医院过渡到家庭过程中的安全性知之甚少。我们的目的是比较出院后早期接受口服抗凝治疗的老年人与晚期接受治疗的老年人的出血和血栓栓塞事件发生率。
我们对2010年9月至2015年3月间安大略省66岁及以上居民进行了一项基于人群的回顾性队列研究，这些居民在出院时开始、继续或恢复口服抗凝治疗。我们计算了在1年随访期内需要住院或急诊就诊的出血和血栓栓塞事件发生率，按出院后的前30天和当年剩余时间分层。我们使用多变量回归模型，对协变量进行调整，以估计性别、既往使用与新发使用以及更换抗凝剂对事件的影响。
共纳入123139例患者（68408例女性[55.6%]；平均年龄78.2岁）。约四分之一（32563例[26.4%]）的Charlson合并症指数评分为2或更高。每100人年的出血和血栓栓塞事件发生率在出院后的前30天最高（分别为25.8，95%CI 24.8 - 26.8和19.3，95%CI 18.4 - 20.2），在随后的11个月中分别降至15.7（95%CI 15.3 - 16.1）和6.9（95%CI 6.6 - 7.1）。多变量分析显示，在医院更换抗凝剂的患者和男性在随访中有更多的出血和血栓栓塞事件。
出院后的最初几周是老年人口服抗凝治疗相关不良事件的极高风险期。这些结果支持在出院后早期进行抗凝管理的干预试验。
