Singer D E
Medical Services, Massachusetts General Hospital, and the Department of Medicine, Harvard Medical School, Boston 02114, USA.
Am J Cardiol. 1998 Mar 12;81(5A):35C-40C. doi: 10.1016/s0002-9149(98)00185-4.
Nonrheumatic atrial fibrillation (AFib) is the most potent common risk factor for stroke, raising the risk of stroke 5-fold. Six randomized trials of anticoagulation in AFib consistently demonstrated a reduction in the risk of stroke by about two-thirds. In these trials, anticoagulation in AFib was quite safe. In contrast, randomized trials indicate that aspirin confers only a small reduction in risk of stroke, at best. Pooled data from the first set of randomized trials indicate that prior stroke, hypertension, diabetes, and increasing age are independent risk factors for future stroke with AFib. Individuals < 65 years old with none of the other risk factors might safely avoid anticoagulation; for all others, anticoagulation seems indicated. Studies of hemorrhagic risk highlight the importance of keeping the international normalized ratio (INR) < 4.0. Recent analyses also reveal that risk of ischemic stroke in AFib increases greatly at INR levels < 2.0. Efficacy and safety of anticoagulation in AFib depend on maintaining the INR between 2.0-3.0. Cost-effectiveness studies indicate that anticoagulation for AFib is among the most efficient preventive interventions in adults. Importantly, the benefits of anticoagulation in AFib accrue immediately. The implications for managed care organizations are that anticoagulation for AFib should be encouraged in their covered populations, and that dedicated anticoagulation services should be developed to promote system-wide control of anticoagulation intensity. Quality measures would include the proportion of patients with AFib who are anticoagulated, and the percentage of time patients' INR levels are between 2.0-3.0. Managed care organizations can benefit from recent research on anticoagulation for AFib; they have a responsibility to support future research and development efforts.
非风湿性心房颤动（AFib）是中风最主要的常见危险因素，使中风风险增加5倍。六项关于AFib抗凝治疗的随机试验一致表明，中风风险降低了约三分之二。在这些试验中，AFib的抗凝治疗相当安全。相比之下，随机试验表明，阿司匹林充其量只能使中风风险略有降低。第一组随机试验的汇总数据表明，既往中风、高血压、糖尿病和年龄增长是AFib患者未来中风的独立危险因素。年龄<65岁且无其他危险因素的个体可能可以安全地避免抗凝治疗；对于其他所有人，似乎都需要进行抗凝治疗。出血风险研究强调了将国际标准化比值（INR）保持在<4.0的重要性。最近的分析还显示，INR水平<2.0时，AFib患者发生缺血性中风的风险会大幅增加。AFib抗凝治疗的有效性和安全性取决于将INR维持在2.0 - 3.0之间。成本效益研究表明，AFib的抗凝治疗是成人中最有效的预防性干预措施之一。重要的是，AFib抗凝治疗的益处会立即显现。对管理式医疗组织的启示是，应鼓励在其覆盖人群中对AFib进行抗凝治疗，并应开发专门的抗凝服务以促进全系统对抗凝强度的控制。质量指标应包括接受抗凝治疗的AFib患者比例，以及患者INR水平在2.0 - 3.0之间的时间百分比。管理式医疗组织可以从最近关于AFib抗凝治疗的研究中受益；它们有责任支持未来的研发工作。
