Sargsyan Davit, Cabrera Javier, Duan Yajie, Ananth Cande V, Kostis William J, Kostis John B
Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA.
Int J Cardiol Cardiovasc Risk Prev. 2022 Mar 25;13:200129. doi: 10.1016/j.ijcrp.2022.200129. eCollection 2022 Jun.
Patients diagnosed with atrial fibrillation (AF) are at increased risk of stroke. Several guidelines to assess the risk of ischemic stroke and major bleeding in AF patients have been published. The score has been adopted widely for predicting stroke within one year of the index AF diagnosis and is used to guide the prescription of anticoagulants. Anticoagulation therapy increases the risk of bleeding and scoring systems such as assess the risk of major bleeding in anticoagulated patients. Despite these advances, no study has examined the risks of the two outcomes simultaneously. How patients' fear of particular outcomes affects these risks also remains unknown.
We incorporated the risks of ischemic stroke and major bleeding within one year of the index AF admission as well as the fear of stroke and bleeding of each individual patient. The patients enrolled in this retrospective observational study were identified using hospital admission data from the Myocardial Infarction Data Acquisition System (MIDAS), a statewide database including all hospitalizations for cardiovascular disease in New Jersey. Probabilities of the outcomes (ischemic stroke, major bleeding, both, or neither within one year of the index AF admission) were estimated using multinomial regression with patient demographics and comorbidities (heart failure [HF], hypertension [HTN], diabetes mellitus [DM], anemia, chronic obstructive pulmonary disease [COPD], kidney disease [KD], prior stroke or transient ischemic attack [TIA]) as predictors. These estimates were used in a Deming regression to model the association of ischemic stroke and major bleeding in grouped patients. The assessment of the importance of each outcome was superimposed on the final model to arrive at a recommendation for anticoagulation therapy.
The results of the Deming regression indicated a positive relationship between ischemic stroke and major bleeding (slope = 1.67, 95% confidence interval [CI] 1.37 to 1.97). Estimates of the risks of the two outcomes and the lines of best fit from Deming regression were determined. This model for risk assessment of stroke and major bleeding within one year of the index AF hospital admission combined objective data and subjective assessment of the relative fear of stroke versus bleeding by each hypothetical patient on 0-100 scale. Examples with the fears of stroke versus major bleeding being equal (50-50) and a higher fear of stroke (80-20) are presented.
The new model for risk assessment of ischemic stroke and major bleeding within one year of the index AF hospital admission proposed in this work used objective, empirically driven measures, and subjective assessment of the outcomes' importance for individual patients. Such models may assist physicians in their decision making regarding anticoagulation therapy.
被诊断为心房颤动（AF）的患者中风风险增加。已发布了多项评估AF患者缺血性中风和大出血风险的指南。[具体评分名称]评分已被广泛用于预测首次AF诊断后一年内的中风情况，并用于指导抗凝剂的处方。抗凝治疗会增加出血风险，而诸如[具体评分名称]等评分系统可评估接受抗凝治疗患者的大出血风险。尽管有这些进展，但尚无研究同时考察这两种结果的风险。患者对特定结果的恐惧如何影响这些风险也仍不明确。
我们纳入了首次AF入院后一年内缺血性中风和大出血的风险，以及每位患者对中风和出血的恐惧。本回顾性观察研究纳入的患者通过心肌梗死数据采集系统（MIDAS）的医院入院数据进行识别，MIDAS是一个全州范围的数据库，包含新泽西州所有心血管疾病住院病例。使用多项回归，以患者人口统计学特征和合并症（心力衰竭[HF]、高血压[HTN]、糖尿病[DM]、贫血、慢性阻塞性肺疾病[COPD]、肾脏疾病[KD]、既往中风或短暂性脑缺血发作[TIA]）作为预测因素，估计这些结果（首次AF入院后一年内发生缺血性中风、大出血、两者皆有或两者皆无）的概率。这些估计值用于Deming回归，以建立分组患者中缺血性中风和大出血之间关联的模型。将对每个结果重要性的评估叠加到最终模型上，以得出抗凝治疗的建议。
Deming回归结果表明缺血性中风和大出血之间存在正相关关系（斜率 = 1.67，95%置信区间[CI]为1.37至1.97）。确定了这两种结果的风险估计值以及Deming回归的最佳拟合线。该首次AF入院后一年内中风和大出血风险评估模型结合了客观数据以及每位假设患者在0 - 100量表上对中风与出血相对恐惧程度的主观评估。给出了中风与大出血恐惧程度相等（50 - 50）以及对中风恐惧程度更高（80 - 20）的示例。
本研究提出的首次AF入院后一年内缺血性中风和大出血风险评估新模型使用了客观的、基于经验的测量方法，以及对个体患者而言结果重要性的主观评估。此类模型可能有助于医生在抗凝治疗决策方面提供帮助。
