Howard P A, Duncan P W
Department of Pharmacy Practice, School of Pharmacy, University of Kansas Medical Center, Kansas City 66160, USA.
Ann Pharmacother. 1997 Oct;31(10):1187-96. doi: 10.1177/106002809703101012.
To review the clinical trials evaluating warfarin for primary stroke prophylaxis in nonvalvular atrial fibrillation (NVAF), to discuss the relative benefits and risks of warfarin versus aspirin therapy, and to review the clinical practice guidelines and identify potential barriers to their implementation in clinical practice.
A MEDLINE literature search was performed to identify clinical trials of antithrombotic therapy for NVAF, clinical practice guidelines, studies evaluating physician practices and attitudes, cost-effectiveness studies, and pertinent review articles. Key search terms included atrial fibrillation, stroke, antithrombotic, warfarin, aspirin, and cost-effectiveness.
Prospective, randomized clinical trials were selected for analysis. Clinical practice guidelines from recognized panels of experts were reviewed. Comprehensive review articles were selected.
NVAF is a common arrhythmia that is associated with a substantial risk for stroke. Seven prospective, randomized, clinical trials have conclusively demonstrated the efficacy of warfarin for stroke prevention. The greatest benefits are achieved in older patients and those with comorbidities that increase their risk for stroke. The potential benefits of preventing a devastating stroke, however, must be weighed against the potential for bleeding complications. Warfarin has been shown to be cost-effective in high-risk patients, provided the rate of complications is minimized. Nonetheless, many physicians remain hesitant to implement warfarin therapy in older, high-risk patients. The clinical data on aspirin are less consistent than those observed with warfarin. Aspirin appears to be most effective in younger individuals or those considered to be at low risk for stroke.
In patients with NVAF, the personal, social, and economic consequences of stroke are often devastating. Clinical trials have provided definitive proof that the risks of stroke can be significantly reduced through the use of appropriate antithrombotic therapy. Despite this evidence and the recommendations of a number of clinical practice guidelines, variations in care exist that continue to place patients at risk. Additional outcomes research is needed to evaluate the impact of the clinical trial findings and practice guidelines on clinical practice and to develop methods for overcoming barriers to implementation.
回顾评估华法林用于非瓣膜性心房颤动（NVAF）患者一级预防中风的临床试验，讨论华法林与阿司匹林治疗的相对益处和风险，并回顾临床实践指南，识别在临床实践中实施这些指南的潜在障碍。
进行了MEDLINE文献检索，以识别NVAF抗栓治疗的临床试验、临床实践指南、评估医生实践和态度的研究、成本效益研究以及相关综述文章。关键检索词包括心房颤动、中风、抗栓、华法林、阿司匹林和成本效益。
选择前瞻性、随机临床试验进行分析。审查了公认专家小组的临床实践指南。选择了全面的综述文章。
NVAF是一种常见的心律失常，与中风的高风险相关。七项前瞻性、随机临床试验已确凿证明华法林预防中风的疗效。在老年患者和有增加中风风险合并症的患者中获益最大。然而，预防严重中风的潜在益处必须与出血并发症的可能性相权衡。已证明在高风险患者中，只要将并发症发生率降至最低，华法林具有成本效益。尽管如此，许多医生在老年、高风险患者中仍对实施华法林治疗犹豫不决。关于阿司匹林的临床数据不如华法林的一致。阿司匹林似乎在年轻个体或被认为中风风险低的个体中最有效。
在NVAF患者中，中风的个人、社会和经济后果往往是毁灭性的。临床试验已提供确凿证据表明，通过使用适当的抗栓治疗可显著降低中风风险。尽管有这些证据和多项临床实践指南的建议，但护理仍存在差异，使患者持续面临风险。需要更多的结局研究来评估临床试验结果和实践指南对临床实践的影响，并开发克服实施障碍的方法。
