The Cardiovascular Institute, Tokyo, Japan.
Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
PLoS One. 2023 Feb 8;18(2):e0280753. doi: 10.1371/journal.pone.0280753. eCollection 2023.
Although anticoagulants are indicated for many elderly patients with non-valvular atrial fibrillation (NVAF), some patients do not receive anticoagulant therapy, whose characteristics and outcomes are diverse.
In this sub-analysis of the All Nippon AF In the Elderly (ANAFIE) Registry, the phenotypes of patients who were not receiving anticoagulants at baseline were evaluated by cluster analysis using Ward's linkage hierarchical algorithm. Of 32,275 enrolled patients, 2445 (7.6%) were not receiving anticoagulants. Two clusters were identified: (1) elderly paroxysmal AF (PAF) patients with a high proportion of catheter ablation history (57%) and (2) very elderly patients with a high prevalence of previous major bleeding (43%). Respective mean ages were 80.9 and 84.2 years, mean CHA2DS2-VASc scores were 3.8 and 4.9, PAF prevalences were 100.0% and 31.4%, proportions of patients with catheter ablation history were 21.0% and 7.9%, and proportions of patients with a history of major bleeding were 4.0% and 10.8%. Annual incidence rates were 2.72% and 8.81% for all-cause death, 1.66% and 5.85% for major adverse cardiovascular or neurological events, 1.08% and 3.30% for stroke or systemic embolism, and 0.69% and 1.19% for major bleeding, respectively.
In this cohort of elderly NVAF patients from the ANAFIE Registry who were not receiving anticoagulants, over half had PAF with a high proportion of catheter ablation history and a low incidence of adverse outcomes; for them, non-prescription of anticoagulants may be partially understandable, but they should be carefully monitored regarding AF burden or atrial cardiomyopathy and be adequately anticoagulated when adverse findings are detected. The remaining were very elderly patients with a high prevalence of previous major bleeding and a high incidence of adverse outcomes; for them, non-prescription of anticoagulants is inappropriate because of the high thromboembolic risk.
Registration: http://www.umin.ac.jp/; Unique identifier: UMIN000024006.
尽管抗凝剂适用于许多患有非瓣膜性心房颤动（NVAF）的老年患者，但仍有部分患者未接受抗凝治疗，这些患者的特征和结局存在差异。
本研究为 ANAFIE 注册研究的亚组分析，采用 Ward 链接层次算法的聚类分析评估了基线时未接受抗凝治疗患者的表型。在纳入的 32275 例患者中，2445 例（7.6%）未接受抗凝治疗。确定了 2 个聚类：（1）老年阵发性 AF（PAF）患者，既往导管消融史比例较高（57%）；（2）高龄患者，既往大出血比例较高（43%）。相应的平均年龄分别为 80.9 岁和 84.2 岁，平均 CHA2DS2-VASc 评分为 3.8 分和 4.9 分，PAF 患病率分别为 100.0%和 31.4%，导管消融史比例分别为 21.0%和 7.9%，大出血史比例分别为 4.0%和 10.8%。全因死亡的年发生率分别为 2.72%和 8.81%，主要心血管或神经不良事件分别为 1.66%和 5.85%，卒中或全身性栓塞分别为 1.08%和 3.30%，大出血分别为 0.69%和 1.19%。
在 ANAFIE 注册研究中，未接受抗凝治疗的老年 NVAF 患者中，超过一半的患者患有 PAF，且既往导管消融史比例较高，不良结局发生率较低；对于这些患者，不处方抗凝剂可能部分可以理解，但应密切监测 AF 负荷或心房心肌病，并在发现不良结果时充分抗凝。其余患者为高龄，既往大出血发生率较高，不良结局发生率较高；对于这些患者，由于血栓栓塞风险较高，不处方抗凝剂是不合适的。
