Briosa E Gala Andre, Pope Michael Timothy Brian, Leo Milena, Sharp Alexander James, Tsoi Victor, Paisey John, Curzen Nick, Betts Timothy Rider
Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
Faculty of Medicine, University of Southampton, Southampton, UK.
Arrhythm Electrophysiol Rev. 2023 Mar 2;12:e05. doi: 10.15420/aer.2022.22. eCollection 2023.
In patients with a low AF burden and long periods of sinus rhythm, 'pill-in-the-pocket' oral anticoagulation (OAC) may, taken as needed in response to AF episodes, offer the same thromboembolic protection as continuous, life-long OAC, while reducing bleeding complications at the same time. The purpose of this study is to systematically summarise available evidence pertaining to the feasibility, safety and efficacy of pill-in-the-pocket OAC.
Medline and Embase were searched from inception to July 2022 for studies adopting a pill-in-the-pocket OAC strategy in AF patients guided by daily rhythm monitoring (PROSPERO/CRD42020209564). Outcomes of interest were extracted and event rates per patient-years of follow-up were calculated. A random effects model was used for pooled estimates.
Eight studies were included (711 patients). Daily rhythm monitoring was continuous in six studies and intermittent in two (pulse checks or smartphone single-lead electrocardiograms were used). Anticoagulation criteria varied across studies, reflecting the uncertainty regarding the AF burden that warrants anticoagulation. The mean time from AF meeting OAC criteria to its initiation was not reported. Adopting pill-in-the-pocket OAC led to 390 (54.7%) patients stopping OAC, 85 (12.0%) patients taking pill-in-the-pocket OAC and 237 (33.3%) patients remaining on or returning to continuous OAC. Overall, annualised ischaemic stroke and major bleeding rates per patient-year of follow-up were low at 0.005 (95% CI [0.002-0.012]) and 0.024 (95% CI [0.013-0.043]), respectively.
Current evidence, although encouraging, is insufficient to inform practice. Additional studies are required to improve our understanding of the relationships between AF burden and thromboembolic risk to help define anticoagulation criteria and appropriate monitoring strategies.
对于房颤负荷较低且窦性心律持续时间较长的患者，“按需服用”口服抗凝药（OAC）在房颤发作时按需服用，可能提供与持续终身服用OAC相同的血栓栓塞保护，同时减少出血并发症。本研究的目的是系统总结有关按需服用OAC的可行性、安全性和有效性的现有证据。
检索Medline和Embase数据库，从建库至2022年7月，查找在每日节律监测指导下对房颤患者采用按需服用OAC策略的研究（PROSPERO/CRD42020209564）。提取感兴趣的结局，并计算每位患者每年随访的事件发生率。采用随机效应模型进行汇总估计。
纳入8项研究（711例患者）。6项研究采用连续每日节律监测，2项采用间歇性监测（使用脉搏检查或智能手机单导联心电图）。各研究的抗凝标准不同，反映了关于需要抗凝的房颤负荷的不确定性。未报告从房颤符合OAC标准到开始服用OAC的平均时间。采用按需服用OAC导致390例（54.7%）患者停用OAC，85例（12.0%）患者采用按需服用OAC，237例（33.3%）患者继续或恢复持续服用OAC。总体而言，每位患者每年随访的缺血性卒中年化率和大出血率较低，分别为0.005（95%CI[0.002-0.012]）和0.024（95%CI[0.013-0.043]）。
目前的证据虽然令人鼓舞，但不足以指导实践。需要更多研究来增进我们对房颤负荷与血栓栓塞风险之间关系的理解，以帮助确定抗凝标准和适当的监测策略。
