低强度抗凝合用洛伐他汀预防房颤患者脑卒中的研究

目的前瞻性研究低强度华法林抗凝合用洛伐他汀对非瓣膜性心房颤动患者脑卒中的预防作用。方法将自愿接受脑卒中预防的628例非瓣膜性心房颤动患者随机分为实验组和对照组各314例。对照组维持目标抗凝强度凝血活酶臣际标准化比率（INR）2．0～3．0;实验组维持目标抗凝强度INR1．5～1．9．并加用洛伐他汀20mg／d,随访7～56个月。结果与对照组比较,实验组出血事件和缺血性卒中的发生率明显降低．5a生存率明显提高。结论低强度华法林抗凝合用洛伐他汀能有效降低非瓣膜性心房颤动患者脑卒中发生率,降低华法林抗凝引起出血的危险性,提高长期生存率。     

高龄非瓣膜性房颤的华法林治疗11例体会

目的:探讨华法林治疗高龄非瓣膜性房颤患者安全有效的抗凝强度。方法:对11例高龄非瓣膜房颤有抗凝适应证者予华法林治疗,将抗凝强度控制在INR为1.5~2.0,观察疗效和出血并发症。结果:观察期间11例患者无致命性出血,仅1例皮肤出血且未停药。7例患者反复发作的短暂性脑缺血发作和脑梗塞症状得到控制。3例有2种以上危险因素的患者未出现栓塞并发症。结论:低抗凝强度(INR1.5~2.0)抗凝对高龄非瓣膜性房颤患者安全有效。     

Emerging oral anticoagulants for stroke prevention in patients with non-valvular atrial fibrillation

In patients with atrial fibrillation (AF) warfarin has been the mainstay therapy for stroke prevention. In recent randomized clinical trials (RCTs) oral direct thrombin inhibitor (Dabigatran) and factor Xa inhibitors (Rivaroxaban and Apixaban) challenged the efficacy and safety benchmarks set by warfarin. These drugs boast a rapid onset of action, shorter half-life and fewer drug and dietary interactions. Moreover, these new anticoagulants do not require monitoring, titration or dose adjustments. These agents have already been approved for prevention of stroke or systemic embolism in patients with AF. Uncertainty regarding suitability, efficacy and safety in certain patient subsets and issues related to the ability effectively monitor the pharmacodynamic effects and reverse the therapeutic effects of these drugs should be addressed as we engage in a widespread use of these agents in various patient subsets.     

Alternatives to chronic warfarin therapy for the prevention of stroke in patients with atrial fibrillation

Atrial fibrillation (AF) is associated with a fivefold increased risk for stroke due to thromboembolic events. Warfarin remains the standard medical therapy for decades in these patients but is difficult to use safely and conveniently. Chronic warfarin therapy is contraindicated in 14% to 44% of patients with AF who are at risk for stroke. In clinical practice, warfarin is prescribed to only 15% to 60% of patients with AF who are at high risk for thromboembolic events and have no clear contraindication to their use. Alternatives to warfarin include (i) antiplatelet therapy; (ii) new oral anticoagulants; and (iii) exclusion of the left atrial appendage (LAA) as a major embolic source. Dual antiplatelet therapy with aspirin and clopidogrel was superior to aspirin alone in reducing the risk of stroke in patients unsuitable to warfarin. Furthermore, a number of newer oral anticoagulants are currently under investigation for stroke prevention in AF. Oral direct thrombin or factor Xa inhibitors are in the most advanced stages of development. Given that about 90% of the source of thromboembolism occurs in the LAA in patients with non-valvular AF, occlusion of flow into the LAA may prevent thrombus formation in the appendage and hence reduction of stroke. Recently, several devices have been employed percutaneously with encouraging results in selected patients. Current review summarizes the latest clinical trial data pertinent to dual-antiplatelet therapy, several newer antithrombotic agents and LAA occlusion.     

非瓣膜病心房颤动或心房扑动患者应用不同起始剂量华法林对INR达标速度的影响

目的观察我国非瓣膜病心房颤动（NVAF）或心房扑动（AFL）患者应用不同起始剂量华法林时,国际标准化比值（INR）首次达标和稳定的时间及出血并发症的发生率等,以进一步了解中国人应用国产华法林的最佳起始剂量。方法人选84例,随机分入起始剂量3．125mg组（第1组）,起始5mg,2d后改为3．125mg组（第2组）和起始5mg治疗组（第3组）。于治疗第3、4、5、7、9天测定INR,根据INR调整华法林剂量,直到INR稳定于1．8～3．0,随访1个月。结果第3组比第1、2组提早达标并稳定,第1、2组差异无统计学意义。3组均无明显出血及血栓栓塞事件,INR增高发生率差异无统计学意义。结论对于中国NVAF或AFL患者,以5mg为初始剂量应用华法林能使INR安全、迅速、有效地达标并稳定。服药3次后即于第4天起测INR是安全的。     

非瓣膜性心房颤动患者的卒中危险因素分析

卒中是非瓣膜性心房颤动(以下简称为房颤)的主要并发症。心力衰竭、高龄、高血压、糖尿病及卒中或短暂性脑缺血发作史与房颤患者卒中的风险相关,此外,临床上其他原因所致的缺血性卒中的危险因素也与房颤患者的卒中风险相关。筛选房颤患者并发卒中的危险因素,并采取有效方法评估其卒中的危险性,无论是对于抗凝治疗预防卒中事件,还是对于减少抗凝治疗引起的出血风险,都具有十分重要的意义。     

International normalized ratio control and subsequent clinical outcomes in patients with atrial fibrillation using warfarin

Journal of Thrombosis and Thrombolysis - We explored associations between INR measures and clinical outcomes in patients with AF using warfarin, and whether INR history predicted future INR...     

非瓣膜病房颤患者脑卒中风险评估方法的探讨

【摘要】目的：探索非瓣膜病房颤患者发生脑卒中的危险因素,建立房颤脑卒中风险评估模型（NewScore）,评价NewScore、CHADS2评分和CHA2DS2-VASC评分三种方法在卒中预测方面的差异,比较三种评分对非瓣膜病房颤患者脑卒中的风险评估能力。方法：对华北理工大学附属煤炭总医院和首都医科大学附属北京市朝阳医院共2家附属教学医院2012年1月至2012年12月收治的首次诊断为非瓣膜病心房颤动的患者进行同群队列研究,收集相关资料,以缺血性脑卒中为终点事件平均随访时间为（27±5）个月。采用χ2检验、wilcoxon 秩和检验（非参方法检验）分析卒中相关危险因素,采用二元logistic回归分析（Enter法）对经单因素分析有统计学意义的参数计算其对模型影响的大小（OR）,组建新的卒中风险评分模型（NewScore）,采用CHADS2、CHA2DS2-VASc和NewScore评分方法对患者依次评分,采用受试者工作特征曲线ROC（Receiver Operating Characteristic）分析比较NewScore、CHADS2评分、CHA2DS2-VASc评分对非瓣膜病房颤患者卒中的预测能力,并记录3个评分系统的95%置信区间、P值、灵敏度、特异度。结果：比较新发脑卒中组和无新发脑卒中组,两组间比较的结果显示年龄、房颤类型、高脂血症病史、冠心病病史、高血压病史、糖尿病病史、既往脑梗死、心肌梗死病史、血管性疾病病史、NT-proBNP、ALT、DBIL、CRP、D-dimer等化验指标存在显著差异（P＜0.05）。将有显著差异的因素进行二元logistic回归分析,结果显示,高脂血症、SBP＞160mmHg、糖尿病、既往脑梗死、血管性疾病与卒中风险独立相关（P＜0.05,OR＞1）,根据各因素的OR值建立NewScore评分,受试者工作特征曲线比较CHADS2评分、CHA2DS2-VASc评分、NewScore评分预测房颤患者随访期间内发生脑卒中的能力,显示受试者工作特征曲线下面积（AUCROC）分别为0.877（0.855-0.900）、0.842（0.817～0.866）和0.850（0.827～0.873）,CHADS2评分的Youden指数0.591,灵敏度0.85,特异度0.741,假阳性率0.259;CHA2DS2-VASc评分的Youden指数0.54,灵敏度0.88,特异度0.66,假阳性率0.34;NewScore评分的Youden指数0.381,灵敏度0.423,特异度0.958,假阳性率0.042。结论：1、高脂血症、SBP＞160mmHg可能为房颤相关脑卒中新的预测因素,心功能不全病史、年龄、性别因素不能增加非瓣膜病房颤患者的脑卒中风险。2、CHADS2评分优于NewScore,NewScore优于CHA2DS2-VASc评分,CHADS2可能更符合住院的非瓣膜病房颤患者的脑卒中风险评估,CHA2DS2-VASc评分在我国的推广使用可能需更多验证。     

非瓣膜性心房颤动患者卒中预防中的抗凝治疗

非瓣膜性心房颤动患者是缺血性卒中的高危人群,临床上主要采用抗凝治疗预防其卒中的发生.然而,常规口服抗凝药华法林因某些限制存在一定的困难.一些新型口服抗凝药,如直接凝血酶抑制药、凝血因子Xa抑制药在非瓣膜性心房颤动患者的卒中预防中显示了其前途.     

非瓣膜病房颤患者脑卒中风险评估的现状

非瓣膜病心房颤动（non-valvular atrial fibrillation,NVAF）是最常见的心律失常之一,其患病率随着年龄的增长而升高,从60岁年龄段的1％增高至85岁以上年龄段的15％[1].房颤可导致心功能恶化、血栓事件的发生.研究显示,NVAF是缺血性脑卒中的独立危险因素,增加卒中风险5倍[2],是房颤患者致残、致死的主要原因.因此对房颤患者如何准确、有效、简单地评估其血栓事件风险,并根据指征进行相应的临床干预显得十分重要.本文在复习国内外文献的基础上,就非瓣膜病房颤患者卒中风险评估的现状作一综述.     

预防心房颤动患者脑卒中的药物治疗新进展

心房颤动(房颤)是最常见的心律失常,有较高的发病率和病死率.患病率随增龄而增加,年龄＜60岁的患者有1%受累,而年龄＞80岁的患者为10%\[1-2].房颤可使栓塞或脑卒中风险增加5倍,每年的绝对风险为1%~20%,取决于患者的年龄和是否存在危险因素,如充血性心力衰竭、高血压、糖尿病和既往栓塞事件[3].     

Pathogenetic mechanism of stroke in non-valvular atrial fibrillation: follow-up of stroke patients with and without atrial fibrillation

Abstract. Stroke patients with brain infarction and non-valvular atrial fibrillation (NVAF, n = 88) or sinus rhythm (SR, n = 188), treated at a population-based stroke unit, were studied for 5 years. Within 1 month, 13% of NVAF and 2% of SR patients (P < 0.01) had either a stroke recurrence or systemic embolism. After 5 years, the corresponding figures were 26 and 25%, respectively. The 1-month and 5-year mortality values were 35 and 78% in the NVAF group vs. 7 and 52% in the SR group (P < 0.01). Age, ischaemic heart disease and function group on arrival at the hospital were independent risk factors for death. The main cause of death was ischaemic heart disease in the NVAF group, and complications to the initial stroke or a stroke recurrence in the SR group. Thus a higher risk of death, stroke recurrence and peripheral embolism was evident only during the first month after stroke.     

Antithrombotic therapy for stroke prevention in atrial fibrillation

Atrial fibrillation (AF) is the most potent common risk factor for ischemic stroke. The number of Americans with nonvalvular AF is expected to increase markedly over the next several decades, making AF-related stroke an important public health concern. Given the individual and societal burden associated with AF-related stroke, efforts to identify and implement efficacious and acceptably safe therapeutic stroke prevention strategies are paramount. This article reviews the existing randomized trial evidence supporting the efficacy of oral vitamin K antagonists (ie, warfarin) or aspirin for preventing thromboembolism in AF, as well as completed and ongoing studies exploring novel antithrombotic agents including the oral direct thrombin inhibitor, ximelagatran, other antiplatelet agents (eg, clopidogrel), factor Xa inhibitors, and other pharmacological agents and additional therapeutic approaches such as mechanical devices and surgical procedures to obliterate the left atrial appendage.     

Efficacy of anticoagulation for secondary stroke prevention in older people with non-valvular atrial fibrillation: a prospective case series study

BACKGROUND AND PURPOSE: Despite large randomised trials that demonstrated the efficacy of oral anticoagulants in the primary and secondary prevention of stroke in patients with non-valvular atrial fibrillation (AF), anticoagulation therapy remains largely under-used in older patients, who are at risk of first ever or recurrent stroke. The aim of the present study was to assess the influence of anticoagulation therapy on long-term prognosis in the oldest old stroke patients with AF after adjusting for baseline risk factors. METHODS: We evaluated prospectively a consecutive series of 207 older people (>75 years) with AF and first ever ischaemic stroke. During the follow-up period (mean 88.4 months, range 3-120), the study population was under either oral anticoagulants (n = 72) or aspirin (n = 135). Death and recurrent vascular events (stroke and systemic embolism) were documented. Statistical analyses were performed by means of the Kaplan-Meier product limit method and the Cox proportional hazards model. RESULTS: The cumulative 10 year mortality and recurrence rate were 92.5% (95% CI 85.7-99.3) and 66.1% (95% CI 43.1-89.1), respectively. Cox regression analysis revealed increasing age, functional dependency at hospital discharge and antiplatelet versus anticoagulation therapy as independent determinants of mortality. Antiplatelet versus anticoagulation therapy was the sole determinant of vascular recurrence. Anticoagulation was associated with decreased risk of death (hazards ratio (HR) 0.47, 95% CI 0.31-0.72, P = 0.001)) and recurrent thromboembolism (HR 0.31, 95% CI 0.16-0.62, P = 0.002). CONCLUSIONS: Our results suggest that the benefits of anticoagulation for secondary stroke prevention in AF patients extend to the oldest old. Prospective randomised clinical trials are needed to verify the potential benefit of anticoagulation in such patients.