Population Health Research Institute, McMaster University Hamilton Canada.
Department of Clinical Sciences Lund University Malmö Sweden.
J Am Heart Assoc. 2024 Sep 3;13(17):e034758. doi: 10.1161/JAHA.123.034758. Epub 2024 Aug 27.
Despite oral anticoagulation, patients with atrial fibrillation (AF) remain at risk of ischemic stroke and systemic embolism (SE) events. For patients whose residual risk is sufficiently high, additional therapies might be useful to mitigate stroke risk.
Individual patient data from 5 landmark trials testing oral anticoagulation in AF were pooled in A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in AF (COMBINE AF). We calculated the rate of ischemic stroke/SE among oral anticoagulation-treated patients with a CHADS-VASc score≥2, across strata of CHADS-VASc score, stroke history, and AF type, as either paroxysmal or nonparoxysmal. We included 71 794 patients with AF (median age 72 years, interquartile range, 13 years, 61.3% male) randomized to a direct oral anticoagulant or vitamin K antagonist, and followed for a mean of 2.1 (±0.8) years. The median CHADS-VASc score was 4 (interquartile range, 3-5), 18.8% had a prior stroke, and 76.4% had nonparoxysmal AF. The overall rate of stroke/SE was 1.33%/y (95% CI, 1.27-1.39); 1.38%/y (95% CI, 1.31-1.45) for nonparoxysmal AF, and 1.15%/y (95% CI, 1.05-1.27) for paroxysmal AF. The rate of ischemic stroke/SE increased by a rate ratio of 1.36 (95% CI, 1.32-1.41) per 1-point increase in CHADS-VASc, reaching 1.67%/y (95% CI, 1.59-1.75) ≥4 CHADS-VASc points. Patients with both nonparoxysmal AF and CHADS-VASc ≥4 had a stroke/SE rate of 1.75%/y (95% CI, 1.66-1.85). In patients with a prior stroke, the risk was 2.51%/y (95% CI, 2.33-2.71).
AF type, CHADS-VASc score, and stroke history can identify patients with AF, who despite oral anticoagulation have a residual stroke/SE risk of 1.5% to 2.5% per year. Evaluation of additional stroke/SE prevention strategies in high-risk patients is warranted.
尽管进行了口服抗凝治疗，房颤（AF）患者仍然存在缺血性卒中和全身性栓塞（SE）事件的风险。对于那些残余风险足够高的患者，可能需要额外的治疗来降低卒中风险。
我们将 5 项评估口服抗凝治疗 AF 的标志性试验的个体患者数据汇总到一个机构间合作项目中，以更好地研究非维生素 K 拮抗剂口服抗凝剂在 AF 中的应用（COMBINE AF）。我们根据 CHADS-VASc 评分≥2 分层，计算口服抗凝治疗患者中缺血性卒中和 SE 的发生率，CHADS-VASc 评分、卒中史和 AF 类型分别为阵发性或非阵发性。我们纳入了 71794 例接受直接口服抗凝剂或维生素 K 拮抗剂治疗的 AF 患者（中位年龄 72 岁，四分位距 13 岁，61.3%为男性），平均随访 2.1（±0.8）年。中位 CHADS-VASc 评分为 4（四分位距 3-5），18.8%有卒中史，76.4%为非阵发性 AF。卒中/SE 的总体发生率为 1.33%/年（95%CI，1.27-1.39）；非阵发性 AF 为 1.38%/年（95%CI，1.31-1.45），阵发性 AF 为 1.15%/年（95%CI，1.05-1.27）。CHADS-VASc 评分每增加 1 分，缺血性卒中和 SE 的发生率增加 1.36（95%CI，1.32-1.41），达到≥4 分 CHADS-VASc 时，发生率为 1.67%/年（95%CI，1.59-1.75）。同时具有非阵发性 AF 和 CHADS-VASc≥4 分的患者卒中/SE 发生率为 1.75%/年（95%CI，1.66-1.85）。有卒中史的患者风险为 2.51%/年（95%CI，2.33-2.71）。
AF 类型、CHADS-VASc 评分和卒中史可识别出 AF 患者，即使进行了口服抗凝治疗，这些患者仍有 1.5%至 2.5%的残余卒中和 SE 风险。需要评估高危患者的其他卒中/SE 预防策略。
