Division of Cardiology, Women's College Hospital, Toronto, Ontario, Canada.
Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine University Health Network, Toronto, Ontario, Canada.
JAMA Cardiol. 2021 Aug 1;6(8):918-925. doi: 10.1001/jamacardio.2021.1232.
There are limited clinical trial data and discrepant recommendations regarding use of anticoagulation therapy in patients with atrial fibrillation (AF) aged 65 to 74 years without other stroke risk factors.
To evaluate the risk of stroke without anticoagulation therapy in men and women with AF aged 66 to 74 years without other CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, female sex) risk factors and examine the association of stroke incidence with patient age.
DESIGN, SETTING, AND PARTICIPANTS: A population-based retrospective cohort study was conducted using linked administrative databases. The population included 16 351 individuals aged 66 to 74 years who were newly diagnosed with AF in Ontario, Canada, between April 1, 2007, and March 31, 2017. Exclusion criteria included long-term care residence, prior anticoagulation therapy, valvular disease, heart failure, hypertension, diabetes, stroke, and vascular disease. The cumulative incidence function was used to estimate the 1-year incidence of stroke in patients who did not receive anticoagulation therapy. Fine-Gray regression was used to study the association of patient characteristics with stroke incidence and derive estimates of stroke risk at each age. Death was treated as a competing risk and patients were censored if they initiated anticoagulation therapy. Inverse probability of censoring weights was used to account for patient censoring. Data analysis was performed from May 26, 2019, to December 9, 2020.
Atrial fibrillation and age.
Hospitalizations for stroke.
Of the 16 351 individuals with AF (median [interquartile range] age, 70 [68-72] years), 8352 (51.1%) were men; 6314 individuals (38.6%) started anticoagulation therapy during follow-up. The overall 1-year stroke incidence among patients who did not receive anticoagulation therapy was 1.1% (95% CI, 1.0%-1.3%) and the incidence of death without stroke was 8.1% (95% CI, 7.7%-8.5%). The incidence of stroke was not significantly associated with sex. The estimated 1-year stroke risk increased with patient age from 66 years (0.7%; 95% CI, 0.5%-0.9%) to 74 years (1.7%; 95% CI, 1.3%-2.1%).
The risk of stroke more than doubled in this study as men and women with AF but no other CHA2DS2-VASc risk factors aged from 66 to 74 years. These data suggest that anticoagulation therapy is more likely to benefit older individuals within this group of patients, whereas younger individuals are less likely to gain net clinical benefit from anticoagulation therapy.
在没有其他卒中危险因素的 65 至 74 岁年龄组的房颤（AF）患者中，关于抗凝治疗的使用，临床研究数据有限，建议也不一致。
评估 66 至 74 岁年龄组无其他 CHA2DS2-VASc（充血性心力衰竭、高血压、年龄≥75 岁、糖尿病、卒中、血管疾病、年龄 65-74 岁、女性）危险因素的 AF 男性和女性患者不接受抗凝治疗的卒中风险，并检查卒中发生率与患者年龄的相关性。
设计、设置和参与者：这是一项基于人群的回顾性队列研究，使用了关联的行政数据库。该人群包括 2007 年 4 月 1 日至 2017 年 3 月 31 日期间在加拿大安大略省新诊断为 AF 的 16351 名年龄在 66 至 74 岁之间的个体。排除标准包括长期护理居住、长期抗凝治疗、瓣膜疾病、心力衰竭、高血压、糖尿病、卒中、血管疾病。使用累积发生率函数估计未接受抗凝治疗的患者卒中的 1 年发生率。精细灰色回归用于研究患者特征与卒中发生率的关系，并在每个年龄得出卒中风险的估计值。死亡被视为竞争风险，如果患者开始抗凝治疗，则对其进行删失。倒数概率删失权重用于解释患者删失。数据分析于 2019 年 5 月 26 日至 2020 年 12 月 9 日进行。
房颤和年龄。
卒中住院。
在 16351 名 AF 患者中（中位数[四分位数间距]年龄，70[68-72]岁），8352 名（51.1%）为男性；6314 名患者（38.6%）在随访期间开始抗凝治疗。未接受抗凝治疗的患者中，1 年卒中总发生率为 1.1%（95%CI，1.0%-1.3%），无卒中死亡的发生率为 8.1%（95%CI，7.7%-8.5%）。卒中发生率与性别无显著相关性。估计的 1 年卒中风险随着患者年龄从 66 岁（0.7%；95%CI，0.5%-0.9%）增加到 74 岁（1.7%；95%CI，1.3%-2.1%）而增加。
在这项研究中，年龄在 66 至 74 岁之间且无其他 CHA2DS2-VASc 危险因素的 AF 男性和女性患者中，卒中风险增加了一倍以上。这些数据表明，抗凝治疗更有可能使该组患者中的老年个体受益，而年轻个体从抗凝治疗中获得的净临床获益则较少。
