Camm Alan John, Steffel Jan, Virdone Saverio, Bassand Jean-Pierre, Fox Keith A A, Goldhaber Samuel Z, Goto Shinya, Haas Sylvia, Turpie Alexander G G, Verheugt Freek W A, Misselwitz Frank, Herreros Ramón Corbalán, Kayani Gloria, Pieper Karen S, Kakkar Ajay K
Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK.
University of Zurich, Zurich, Switzerland.
Eur Heart J Open. 2023 May 19;3(3):oead051. doi: 10.1093/ehjopen/oead051. eCollection 2023 May.
This study aimed to identify relationships in recently diagnosed atrial fibrillation (AF) patients with respect to anticoagulation status, use of guideline-directed medical therapy (GDMT) for comorbid cardiovascular conditions (co-GDMT), and clinical outcomes. The Global Anticoagulant Registry in the FIELD (GARFIELD)-AF is a prospective, international registry of patients with recently diagnosed non-valvular AF at risk of stroke (NCT01090362).
Guideline-directed medical therapy was defined according to the European Society of Cardiology guidelines. This study explored co-GDMT use in patients enrolled in GARFIELD-AF (March 2013-August 2016) with CHADS-VASc ≥ 2 (excluding sex) and ≥1 of five comorbidities-coronary artery disease, diabetes mellitus, heart failure, hypertension, and peripheral vascular disease ( = 23 165). Association between co-GDMT and outcome events was evaluated with Cox proportional hazards models, with stratification by all possible combinations of the five comorbidities. Most patients (73.8%) received oral anticoagulants (OACs) as recommended; 15.0% received no recommended co-GDMT, 40.4% received some, and 44.5% received all co-GDMT. At 2 years, comprehensive co-GDMT was associated with a lower risk of all-cause mortality [hazard ratio (HR) 0.89 (0.81-0.99)] and non-cardiovascular mortality [HR 0.85 (0.73-0.99)] compared with inadequate/no GDMT, but cardiovascular mortality was not significantly reduced. Treatment with OACs was beneficial for all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use; only in patients receiving all co-GDMT was OAC associated with a lower risk of non-haemorrhagic stroke/systemic embolism.
In this large prospective, international registry on AF, comprehensive co-GDMT was associated with a lower risk of mortality in patients with AF and CHADS-VASc ≥ 2 (excluding sex); OAC therapy was associated with reduced all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use.
Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362.
本研究旨在确定近期诊断为心房颤动（AF）的患者在抗凝状态、针对合并心血管疾病使用指南导向的药物治疗（co-GDMT）以及临床结局方面的关系。FIELD全球抗凝注册研究（GARFIELD）-AF是一项针对近期诊断为有卒中风险的非瓣膜性AF患者的前瞻性国际注册研究（NCT01090362）。
指南导向的药物治疗根据欧洲心脏病学会指南进行定义。本研究探讨了GARFIELD-AF（2013年3月至2016年8月）中CHADS-VASc≥2（不包括性别）且患有以下五种合并症（冠状动脉疾病、糖尿病、心力衰竭、高血压和外周血管疾病）中至少一种的患者（n = 23165）的co-GDMT使用情况。使用Cox比例风险模型评估co-GDMT与结局事件之间的关联，并按五种合并症的所有可能组合进行分层。大多数患者（73.8%）按推荐接受了口服抗凝剂（OAC）；15.0%未接受推荐的co-GDMT，40.4%接受了部分co-GDMT，44.5%接受了全部co-GDMT。在2年时，与不充分/未接受GDMT相比，全面的co-GDMT与全因死亡率降低相关[风险比（HR）0.89（0.81 - 0.99）]和非心血管死亡率降低相关[HR 0.85（0.73 - 0.99）]，但心血管死亡率未显著降低。OAC治疗对全因死亡率和非心血管死亡率有益，无论是否使用co-GDMT；仅在接受全部co-GDMT的患者中，OAC与较低的非出血性卒中/系统性栓塞风险相关。
在这项关于AF的大型前瞻性国际注册研究中，全面的co-GDMT与AF且CHADS-VASc≥2（不包括性别）患者的较低死亡率风险相关；OAC治疗与降低全因死亡率和非心血管死亡率相关，无论是否使用co-GDMT。
