School of Medicine, Monash University, Clayton, Australia.
Section of Epidemiology and Biostatistics, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
BMC Cardiovasc Disord. 2021 Apr 23;21(1):206. doi: 10.1186/s12872-021-01993-9.
Antithrombotic medications (antiplatelets and anticoagulants) reduce the risk of cardiovascular disease (CVD), but with the disadvantage of increasing bleeding risk. Ethnicity and socioeconomic deprivation are independent predictors of major bleeds among patients without CVD, but it is unclear whether they are also predictors of major bleeds among patients with CVD or atrial fibrillation (AF) after adjustment for clinical variables.
Prospective cohort study of 488,107 people in New Zealand Primary Care (including 64,420 Māori, the indigenous people of New Zealand) aged 30-79 years who had their CVD risk assessed between 2007 and 2016. Participants were divided into three mutually exclusive subgroups: (1) AF with or without CVD (n = 15,212), (2) CVD and no AF (n = 43,790), (3) no CVD or AF (n = 429,105). Adjusted hazards ratios (adjHRs) were estimated from Cox proportional hazards models predicting major bleeding risk for each of the three subgroups to determine whether ethnicity and socioeconomic deprivation are independent predictors of major bleeds in different cardiovascular risk groups.
In all three subgroups (AF, CVD, no CVD/AF), Māori (adjHR 1.63 [1.39-1.91], 1.24 [1.09-1.42], 1.57 [95% CI 1.45-1.70], respectively), Pacific people (adjHR 1.90 [1.58-2.28], 1.30 [1.12-1.51], 1.62 [95% CI 1.49-1.75], respectively) and Chinese people (adjHR 1.53 [1.08-2.16], 1.15 [0.90-1.47], 1.13 [95% CI 1.01-1.26], respectively) were at increased risk of a major bleed compared to Europeans, although for Chinese people the effect did not reach statistical significance in the CVD subgroup. Compared to Europeans, Māori and Pacific peoples were generally at increased risk of all bleed types (gastrointestinal, intracranial and other bleeds). An increased risk of intracranial bleeds was observed among Chinese and Other Asian people and, in the CVD and no CVD/AF subgroups, among Indian people. Increasing socioeconomic deprivation was also associated with increased risk of a major bleed in all three subgroups (adjHR 1.07 [1.02-1.12], 1.07 [1.03-1.10], 1.10 [95% CI 1.08-1.12], respectively, for each increase in socioeconomic deprivation quintile).
Ethnicity and socioeconomic status should be considered in bleeding risk assessments to guide the use of antithrombotic medication for the management of AF and CVD.
抗血栓药物（抗血小板和抗凝剂）降低了心血管疾病（CVD）的风险，但也增加了出血风险。在没有 CVD 的患者中，种族和社会经济贫困是主要出血的独立预测因素，但在调整了临床变量后，它们是否也是 CVD 或房颤（AF）患者发生主要出血的预测因素尚不清楚。
这是一项在新西兰初级保健中心（包括 64420 名新西兰原住民毛利人）中进行的前瞻性队列研究，纳入了 488107 名年龄在 30-79 岁之间的人群，这些人在 2007 年至 2016 年间进行了 CVD 风险评估。参与者被分为三个互斥的亚组：（1）伴有或不伴有 CVD 的 AF（n=15212）；（2）CVD 而无 AF（n=43790）；（3）无 CVD 或 AF（n=429105）。通过 Cox 比例风险模型对每个亚组的主要出血风险进行调整后，估计了调整后的危险比（adjHR），以确定在不同心血管风险组中，种族和社会经济贫困是否是主要出血的独立预测因素。
在所有三个亚组（AF、CVD、无 CVD/AF）中，毛利人（adjHR 1.63[1.39-1.91]、1.24[1.09-1.42]、1.57[95%CI 1.45-1.70]）、太平洋岛民（adjHR 1.90[1.58-2.28]、1.30[1.12-1.51]、1.62[95%CI 1.49-1.75]）和中国人（adjHR 1.53[1.08-2.16]、1.15[0.90-1.47]、1.13[95%CI 1.01-1.26]）与欧洲人相比，出血风险增加，尽管对于中国人来说，这种影响在 CVD 亚组中没有达到统计学意义。与欧洲人相比，毛利人和太平洋岛民普遍存在所有出血类型（胃肠道、颅内和其他出血）的风险增加。中国人和其他亚洲人颅内出血风险增加，而在 CVD 和无 CVD/AF 亚组中，印度人颅内出血风险增加。在所有三个亚组中（adjHR 1.07[1.02-1.12]、1.07[1.03-1.10]、1.10[95%CI 1.08-1.12]，每增加一个社会经济剥夺五分位数），社会经济剥夺程度的增加也与主要出血风险的增加相关。
在评估出血风险时，应考虑种族和社会经济地位，以指导抗血栓药物在 AF 和 CVD 管理中的应用。
