单中心心房颤动患者流行病学特点和抗凝治疗现状分析

目的 分析区域内单中心房颤人群流行病特点及抗凝现状。方法 收集2019年12月至2021年6月期间就诊于石河子市人民医院的房颤患者702例,随访半年(出院1、3和6个月),分析人群流行病学特点、栓塞/出血风险评估(CHA2DS2-VASc/HAS-BLED评分)分布特征、随访6个月时新发事件(急性冠脉事件、急性心力衰竭、新发脑血管病、出血事件、血栓事件、再次住院、死亡)的发生率,以及影响抗凝治疗的主要因素。结果 1)702例房颤患者平均年龄(73.96±11.27)岁,男352例、女350例,常见伴随疾病有高血压(38.89%)、冠心病(50.57%)、心力衰竭(49.19%)、心脏瓣膜病(1.42%)、糖尿病(56.27%),主要以阵发性房颤(40.02%)和永久性房颤(31.19%)为主,房颤人群总体抗凝率为64.10%;CHA2DS2-VASc评分≥2分人群中,未口服抗凝药物患者224例(占总房颤人群31.91%),口服抗凝药物患者425例(占总房颤人群60.54)。702例患者中使用华法林抗凝患者112例(15.60%)、新型抗凝药物(NOAC,包括利伐沙班、达比加群酯和艾多沙班)338例(48.15%),本地区房颤人群服用抗凝药物种类以NOAC为主。2)对口服华法林抗凝人群随访半年,发现自行停用华法林抗凝药物的患者13例(10.66%),在出院1、3个月时国际标准化比值(INR)达标率最高(59.82%、73.21%),出院6个月时INR达标率下降至58.93%。3)随访半年中,记录到新发脑血管疾病4例,其中未抗凝组3例、抗凝组1例;栓塞事件2组均为1例;再住院分别为17例、13例;死亡分别为3例、2例。结论 本地区房颤好发于老年人,抗凝率总体良好,多数患者以口服NOAC为主;出院6个月时患者华法林INR达标率明显下降。     

华法林改善非瓣膜性心房颤动71例血浆高凝状态指标分析

目的 观察华法林改善非瓣膜性心房颤动患者血浆高凝状态指标.方法 连续选择近期在我院心内科住院的非瓣膜性持续性心房颤动患者71例,后者接受了华法林抗凝治疗,初始口服剂量为1.25 mg/d,根据INR进行调整,维持INR在2.0～3.0之间.治疗前和服药1个月后检测各种血凝指标.结果 71例非瓣膜性心房颤动患者经华法林抗凝治疗1个月后,血浆D-二聚体、纤维蛋白原、凝血酶原时间、部分凝血活酶时间和国际标准化比值均明显低于治疗前(P均＜0.01～0.05).结论 口服华法林可显著改善非瓣膜性房颤患者血浆高凝状态指标.     

房颤相关卒中后的治疗:利伐沙班vs华法林

正心房颤动(a-fib)相关的急性缺血性脑卒中患者,有很高的复发性卒中和颅内出血的风险。本研究比较了非维生素K拮抗剂的口服抗凝血剂(NOAC)——利伐沙班,与剂量调整后的华法林,在轻度房颤相关急性缺血性卒中患者中的疗效和安全性。受试者是患急性缺血性卒中合并非瓣膜性房颤的患者。受试者被随机分为服用利伐沙班或华法林,华法林组国际标准化比率(INR)调整至2-3。利伐沙班组,前5天每日服用利伐沙班10mg,此后每日20mg。华法林组药物控制在INR2-3。在第4周,进行MRI检查以     

品管圈对降低院外非瓣膜性房颤患者口服华法林INR非达标率的作用

目的:探讨品管圈对降低院外非瓣膜性房颤患者口服华法林INR非达标率的作用。方法:由9名心内科护士自愿组成品管圈活动小组,活动主题为降低院外非瓣膜性房颤患者口服华法林INR非达标率,按照品管圈活动步骤实施和评价,比较活动前后非瓣膜性房颤患者INR非达标率及圈员自我评价。结果:实施品管圈活动后,患者非INR达标率低于活动前;活动后圈员自我评分高于活动前(P 0. 05)。结论:品管圈活动在降低非瓣膜性房颤患者INR非达标率中效果显著,提升护士的综合素质。     

1例华法林过量致皮下大面积出血患者并发室速、室颤的护理

血栓栓塞是心房颤动(简称房颤)最危险的并发症,但栓塞事件可通过口服抗凝剂得以降低,华法林因其较低的价格及肯定的药物疗效,被大多数人作为抗凝首选,非瓣膜病房颤患者应用华法林,卒中风险下降64％,全因死亡减少26％[1].合适的华法林抗凝强度要求INR在2.0～3.0,<2.0易致栓塞性疾病,>3.0出血事件增加[2].然而由于华法林个体差异大,治疗窗窄,与其他药物相关作用复杂,因此出血仍然是华法林抗凝最常见的并发症.     

非瓣膜性心房颤动并发缺血性脑卒中的防治

目的　探讨华法林和阿司匹林预防非瓣膜性心房颤动 (房颤 )并发缺血性脑卒中的有效性和安全性。方法　 14 0例持续性房颤患者分为高危组和低危组 :高危组患者 10 0例 ,其中 5 4例接受口服华法林治疗 (INR目标值 1 6～ 2 5 ) ,4 6例口服肠溶阿司匹林 (10 0mg d)治疗 ;低危组 4 0例口服肠溶阿司匹林(10 0mg d)治疗。结果　高危组华法林的维持剂量 (2 6 8± 1 0 5 )mg ,INR值 1 82～ 2 4 9,随访期间无缺血性脑卒中事件发生 ,3例发生出血并发症 (INR 2 8～ 3 2 ) ;高危组阿司匹林治疗的 1例患者发生缺血性脑卒中 ;低危组患者无 1例发生缺血性脑卒中。结论　低强度华发林抗凝治疗可有效预防非瓣膜性房颤高危患者缺血性脑卒中的发生 ,并减少出血并发症 ;阿司匹林 (10 0mg d)可有效预防低危患者缺血性脑卒中事件的发生。     

超高龄心房颤动患者华法林抗凝过程中心血管不良事件的观察

目的: 观察超高龄房颤患者采用不同强度华法林抗凝后的心血管不良事件发生情况,探讨此类患者国际标准化比值(international normalized ratio,INR)的合理范围,为临床提供依据。方法: 将108例超高龄房颤患者（年龄≥80岁）按INR值分为中等强度抗凝组（56例）和低等强度抗凝组（52例）;低等强度抗凝组的INR维持在1.40~1.80;中等强度抗凝组的INR维持在1.81~2.50。随访（1.8±1.2）年,观察发生主要终点事件（缺血性卒中、全身性栓塞）、次要终点事件（非致命性心肌梗死、全因死亡联合终点）、安全性终点事件（致命性出血、严重出血和轻度出血）的情况。结果: 随访期间,中等强度抗凝组中有3例患者发生栓塞,发生率为5.36%;低等强度抗凝组中有6例发生栓塞,发生率为11.54%,均为脑卒中,2组间差异有统计学意义（P<0.05）。低等强度抗凝组中2例、中等强度抗凝组中3例患者出现眼结膜、鼻出血等不良反应,但均无严重出血,2组间出血发生率差异无统计学意义（P>0.05）。结论: 超高龄房颤患者应用华法林,INR维持在1.81~2.50是安全、有效的。     

心房颤动患者应用华法林抗凝治疗的护理体会

目的 总结对心房颤动（房颤）患者应用华法林抗凝治疗的用药指导和护理体会。方法 96例房颤患者应用华法林抗凝治疗，服用前强化健康教育，服用期间监测凝血酶原时间（PT）及其国际标准化比率（INR），观察其抗凝效果及主要不良反应。结果 经过正规的抗凝治疗和护理，未出现血栓栓塞事件发生，2例患者出现轻微皮下出血，经调整华法林剂量后出血停止，无严重出血发生。结论 服用华法林的房颤患者应定期监测PT及INR。早期发现出血的征象并加强健康教育，可避免严重并发症的发生。     

不同抗凝强度的华法林对非瓣膜性心房纤颤抗栓的疗效

目的:探讨阿司匹林和不同抗凝强度华法林对预防非瓣膜性心房纤颤患者血栓栓塞发生的疗效和安全性.方法:选择172例非瓣膜性心房纤颤患者,随机分为阿司匹林组48例、低强度华法林抗凝组38例[国际标准化比值(INR)1.6～2.0]和中强度华法林抗凝组42例(INR 2.1～2.5)、高强度华法林抗凝组44例(INR 2.6～3.5),应用华法林抗凝并行INR监测,常规门诊随访2年,分析血栓栓塞和出血事件发生与INR的关系.结果:治疗后低、中、高强度华法林3组血栓栓塞发生率相当(P>0.05),华法林3组血栓栓塞发生率低于阿司匹林组(P<0.05),高强度华法林组出血发生率高于其他3组(P<0.05),低、中强度华法林组出血发生率与阿司匹林组大致相仿(P>0.05).结论:对非瓣膜性心房纤颤患者华法林(INR 1.6～2.5)抗栓治疗的疗效优于阿司匹林,出血发生率低,安全性好.     

慢性房颤患者华法林抗凝治疗体会

目的:提高华法林在房颤患者抗凝治疗中的使用率,以减少房颤患者脑卒中的发生率。强调需密切监测标准化比值(INR),以减少华法林的出血不良反应。方法:总结2002年6月～2008年6月使用华法林抗凝治疗的房颤患者148例,进行回顾性分析。结果:房颤患者使用华法林抗凝治疗后脑卒中的年发生率为1.8%、年出血并发症为0.76%,分别低于文献报道的4%及1%。结论:无抗凝禁忌症的房颤患者,均应使用华法林抗凝治疗,但应密切监测INR,确保华法林的安全使用。     

脑梗死合并心房颤动358例抗凝治疗状况分析

目的 了解心房颤动伴脑梗死住院患者抗凝治疗的情况,并比较与指南建议之间的差距.方法 对我院2008年1月至2012年6月收治的358例脑梗死合并心房颤动患者的临床资料进行回顾性分析,重点分析抗凝药物使用情况.结果 358例患者中254例既往有心房颤动史（70.9％）,在脑梗死发病前服用过华法林者11例,占有心房颤动病史患者的4.3％;11例患者国际标准化比值（INR）均＜1.5.出院患者中,20.9％接受华法林抗凝治疗.使用华法林与HAS-BLED评分,MRS评分及抗血小板药物呈负相关（OR分别为-1.974、-0.725、-4.170,P＜0.05或P＜0.01）.出院后给予华法林治疗的患者中,33.8％长期坚持服用华法林,用药剂量中位数为2.5 mg（1.25～3.75 mg）,INR控制在1.5～3.1之间.患者平均1个月（2周～2个月）复查一次凝血常规,INR在治疗目标范围内的时间百分比平均为（61.6±21.2）％.结论 脑梗死合并心房颤动患者的抗凝治疗率和INR达标率均较低,对出血的担忧和监测INR的不便影响了华法林的使用.     

Personalizing oral anticoagulant treatment in patients with atrial fibrillation

For decades, warfarin has remained the standard oral anticoagulation for stroke prevention in atrial fibrillation (AF). Three novel oral anticoagulants (NOACs) have been recently approved for stroke prevention in non-valvular AF: dabigatran, rivaroxaban and apixaban. Better pharmacological and clinical profiles make these newcomers a preferable alternative over warfarin. Current AF guidelines do not endorse NOACs over warfarin, or one NOAC over another. Indeed, choice of the anticoagulation regimen should be personalized based on the relative efficacy and safety of different agents across subgroups stratified by thrombotic and bleeding risk, as well as on other clinical factors, including anticoagulation control on warfarin, drug interactions, compliance and need for coagulation monitoring. This review appraises i) the randomized evidence on approved NOACs versus warfarin in AF across subgroups stratified by risk factors of stroke and bleeding and by the anticoagulation level reached on warfarin; and ii) clinical factors impacting on the anticoagulation regimen selection.     

Atrial fibrillation and stroke

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The prevalence of AF is 0.4% in the general population and increases with age up to 6-8% in octogenarians. In Switzerland, approximately 68,000 persons are in atrial fibrillation, and in the EU countries 3.5 millions. Atrial fibrillation disturbs synchronous mechanical atrial activity and impairs the haemodynamics. This can give rise to thrombus formation, mostly in the left atrial appendage, and embolism to the systemic circulation. Clinical manifestations are most often neurological such as transient ischaemic attacks or ischaemic strokes, on average 5% per year. Of all strokes, one in every six occurs in patients with AF. Antiarrhythmic therapy is useful to improve cardiac rate and function in AF. However, to reduce first or recurrent emboli, antithrombotic therapy is of paramount importance. Adjusted-dose warfarin reduces first or recurrent strokes by about 60%. When patients with non-valvular AF are anticoagulated, the odds against ischaemic stroke and intracranial bleeding favour an INR between 2.0 and 3.0. Acetylsalicylic acid is less efficacious than warfarin in AF patients, reducing the risk of stroke by about 20%. Therefore, anticoagulation is the current treatment modality in AF patients at high or intermediate risk, i.e. patients with history of transient ischaemic attack or stroke, those aged > 65 years, those with a history of hypertension, diabetes, heart failure or structural heart disease, valvular disease or significant systolic dysfunction. Antiplatelet agents should be used only for young (< 65 years) AF patients at low risk.     

Aspirin in stroke prevention in nonvalvular atrial fibrillation and stable vascular disease: an era of new anticoagulants

Atrial fibrillation (AF) is a major cause of ischemic stroke, especially in the elderly. There are currently enough data to support the notion that anticoagulation with warfarin or dabigatran is far superior to aspirin in the prevention of stroke or systemic embolism in AF. Aspirin is the preferred modality in patients who are either not candidates for anticoagulation, such as patients with increased risk for bleeding, low-risk patients based on the CHADS2 score or patients who have difficulty in maintaining a therapeutic international normalized ratio. There is no dispute on the recommendations regarding stroke prevention in high-risk patients (CHADS2 risk score of 2 and beyond) with AF. However, there is some controversy regarding the appropriate strategy (anticoagulation vs aspirin) for stroke prevention in low-risk patients (CHA2DS2-VASc score of 0-1). Novel oral anticoagulant drugs (direct thrombin inhibitors and Factor Xa inhibitors) might further diminish the role of aspirin for stroke prevention in AF due to their superior efficacy, lack of need for monitoring of therapeutic effects and lower bleeding risk when compared with warfarin, especially in patients with stable vascular disease.     

不同抗凝强度华法林预防非瓣膜性房颤血栓栓塞的临床研究

目的：探讨不同抗凝强度华法林应用于非瓣膜性心房颤动患者的可行性及安全性。方法：91例非瓣膜性心房颤动患者随机分为三组：低抗凝强度[国际标准化比率（INR）1．5～1．91;标准抗凝强度组（INR2．0～2．5）和阿司匹林组,观察三组血栓栓塞并发症和出血等不良反应的发生率以及c-反应蛋白浓度变化。结果：标准抗凝强度组血栓发生率低于低抗凝强度组、阿司匹林组,不同强度华法林抗凝组血栓栓塞率比较差异无统计学意义;标准抗凝强度组出血发生率低于其他两个组,但三组患者出血发生率比较无统计学意义（P〉O．05）;治疗后低抗凝强度组、标准抗凝强度组c-反应蛋白浓度明显低于治疗前（P〈O．05）,治疗后阿司匹林组c-反应蛋白水平明显高于低抗凝强度组、标准抗凝强度组（P〈0．01）。结论：华法林抗凝维持INR值在2．O～2．5时能降低非瓣膜性房颤患者血栓栓塞发生率,出血发生率低,有效性和安全性好。     

The increasing need for anticoagulant therapy to prevent stroke in patients with atrial fibrillation

Ischemic stroke, a major complication of atrial fibrillation (AF), is believed to result from atrial thrombus formation caused by ineffective atrial contraction. Oral anticoagulant therapy effectively reduces the risk of ischemic stroke in patients with AF; this therapy is recommended for patients with any frequency or duration of AF and other risk factors for stroke, such as increased age (>75 years), hypertension, prior stroke, left ventricular dysfunction, diabetes, or heart failure. Recently published data comparing rate-control and rhythm-control strategies in AF emphasized the importance of maintaining an international normalized ratio higher than 2.0 during warfarin therapy and the need for continuing anticoagulant therapy to prevent stroke in high-risk patients, even if the strategy is rhythm control. Hemorrhagic complications can be minimized by stringent control of the international normalized ratio (particularly in elderly patients) and appropriate therapy for comorbidities such as hypertension, gastric ulcer, and early-stage cancers. Undertreatment of patients with AF is a continuing problem, particularly in the elderly population. Patients perceived as likely to be noncompliant, such as the functionally impaired, are less likely to receive warfarin therapy. However, stroke prevention with anticoagulants is cost-effective and improves quality of life, despite the challenges of maintaining appropriate anticoagulation with monitoring and warfarin dose titration. New medications in development with more predictable dosing and fewer drug-drug interactions may reduce the complexities of achieving optimal anticoagulation and increase the practicality of long-term anticoagulant therapy for patients with AF at risk of stroke.     

Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation

The most severe consequence of atrial fibrillation (AF) is a cardioembolic stroke. The incidence of cardioembolic stroke increases significantly in patients with AF. Although warfarin has been the mainstay of the prevention of cardioembolic stroke, there are several limitations to the use of warfarin that hinder its effectiveness. This article provides the historical development of devices that exclude the left atrial appendage, their effectiveness and potential patient selection, as an alternative to warfarin and the novel oral anticoagulation therapy for the prevention of cardioembolic stroke in patients with AF.