非瓣膜性房颤抗凝治疗临床观察

目的：探讨抗凝治疗非瓣膜性房颤（NVAF）的临床效果及药物选择。方法回顾性分析本院近5年内科住院治疗的NVAF患者96例,随机分为华法令组32例,予华法令1.25~5 mg/d,维持国际标准化比值（INR）2.0~3.0;通心络胶囊联合阿司匹林组32例,予通心络胶囊0.78 g,3次/d,阿司匹林片100 mg/d;阿司匹林组32例,予阿司匹林片100 mg/d。观察和比较三组患者脑栓塞及出血等并发症发生率,随访2年。结果脑栓塞年发病率华法令组（3.33%）与通心络胶囊联合阿司匹林组（5.0%）比较差异无统计学意义（P〉0.05）;阿司匹林组（17.2%）与通心络胶囊联合阿司匹林组比较差异有统计学意义（P〈0.05）;华法令组与阿司匹林组比较差异有统计学意义（P〈0.01）。华法令组有1例脑出血;通心络胶囊联合阿司匹林组有4例出现上腹痛、恶心,1例出现牙龈肿痛;阿司匹林组有3例出现上腹痛、恶心。结论通心络胶囊联合阿司匹林预防NVAF患者脑栓塞的效果和华法令比较差异无统计学意义,优于单用阿司匹林,无严重不良反应发生,且不需要监测凝血酶原时间（PT）和INR。不愿意接受华法令治疗的NVAF患者,给予通心络胶囊联合阿司匹林预防脑栓塞并发症是安全有效的。     

通心络胶囊治疗慢性房颤60例

目的观察通心络胶囊在慢性房颤抗凝治疗中的疗效与安全性。方法将106例慢性房颤患者随机分为治疗组60例和对照组46例,在治疗原发病和控制心室率的基础上,治疗组口服通心络胶囊（2粒／次,3次／d）,对照组口服华法令片（3mg／次,1次／d）。两组均随访4年,观察血栓栓塞及出血等并发症的发生情况。结果治疗组与对照组的抗凝疗效差异无统计学意义（P〉0．05）,但治疗组不良反应较少。结论在相同的抗血栓栓塞并发症的疗效下,服用通心络胶囊比华法令片更安全、方便。     

中西药联合治疗冠心病心绞痛临床观察

目的对中药通心络胶囊联合西药单硝酸异山梨酯片（鲁南欣康）治疗冠心病心绞痛的疗效及安全性作出评价。方法选择126例冠心病心绞痛（胸痹心痛）患者,采用随机对照的方法,治疗组65例,给予通心络胶囊3粒（0．38∥粒）,3次／d和鲁南欣康20mg,2次／d;对照组61例,给予鲁南欣康20mg,2次／d;8周后对心绞痛、心电图、临床症状及安全性指标进行评估。结果心绞痛总有效率治疗组为95．38％,对照组为75．41％（P〈0．05）;心电图总有效率为78．46％,对照组为52．46％（P〈0．05）;临床症状总有效率治疗组为96．92％,对照组为73．77％（P〈0．05）。结论中药通心络胶囊联合西药单硝酸异山梨酯片（鲁南欣康）治疗冠心病心绞痛能明显提高冠心病心绞痛的治疗效果。     

通心络胶囊治疗不稳定型心绞痛疗效观察

目的探讨通心络胶囊治疗不稳定型心绞痛的效果与安全性。方法120例不稳定型心绞痛患者随机分为两组：对照组60例,给予常规药物治疗（拜阿司匹林每次100mg,1次／d;倍他乐克12．5mg酌情加减剂量,2次／d;硝酸甘油0．5-1mg,发作时舌下含服;辛伐他汀10mg,10：／d,晚间顿服;低分子肝素5000uiHq12h,使用7d）;观察组60例,在常规药物治疗基础上加用通心络胶囊4粒,30：／d,餐后0．5h口服,4周为1疗程。观察两组患者的总疗效、心绞痛疗效、心电图疗效、血脂、凝血四项等指标变化。结果观察组总有效率83．33％,显效率41．67％,其心绞痛缓解总有效率93．33％,显效率51．67％。心电图疗效总有效率86．67％,显效率41．67％;观察组能够显著降低总胆固醇（TC）和低密度脂蛋白（LDL—C）水平,提高高密度脂蛋白（HDL—C）,延长凝血酶时间（TT）,与对照组相比上述指标均具有显著差异（P〈0．05）。结论通心络胶囊能够显著缓解不稳定型心绞痛患者的心绞痛症状,改善血脂水平、凝血功能和心肌缺血的心电图表现。     

持续华法林治疗对起搏器植入术后囊袋血肿的影响

目的观察围术期继续应用华法林对起搏器囊袋血肿发生率的影响。方法180例服用华法林的患者接受永久起搏器植入,按照随机表随机分成继续华法林组和肝素桥接组,各90例。继续华法林组患者给予围术期内监测凝血酶原国际化比值,并维持华法林治疗（华法林剂量3．0—6．0mg）;肝素桥接组患者围术期内采用低分子肝素桥接[1mg／（kg·12h）],观察住院期间2周内囊袋的血肿发生率。结果继续华法林组囊袋血肿发生率为6．7％（6／90）,肝素桥接组为17．8％（16／90）,2组比较差异有统计学意义（P=0．023）。Logistic回归分析显示低分子肝素为发生囊袋血肿的独立危险因素（RR=2．665,95％CI=1．073—8．156,P=0．023）。结论与肝素桥接法比较,围术期继续服用华法林不明显增加起搏器囊袋血肿发生率。     

华法林在非瓣膜病性心房颤动中的应用观察

目的探讨华法林对于非瓣膜病性心房颤动（房颤）患者抗凝治疗的安全性及疗效。方法将符合本研究标准的60例房颤患者采用完全随机设计方法分为治疗组和对照组。治疗组30例，给予华法林（2．5～3．0）mg／d治疗，监测国际标准化比值（INR），连续观察4周，据INR结果调整华法林口服剂量，以后查INR 1次／月。对照组30例，给予阿司匹林肠溶片300mg／d。门诊随访记录各类并发症及脑卒中和血检性并发症，随访1年后进行对比分析。结果2组发生出血无统计学意义，但治疗组脑梗死率与对照组相比明显降低（P〈0．05）。治疗组1例牙龈、皮下出血，1例牙龈、尿路出血，1例脑梗死。对照组1例牙龈出血，8例脑梗死。结论非瓣膜病性房颤患者应用适量华法林抗凝治疗是安全有效的。     

华法林与阿司匹林对老年房颤患者脑卒中发病率的影响

目的对比华法林和阿司匹林对老年性非瓣膜性房颤患者脑卒中发病率的影响。方法将110例老年非瓣膜性房颤患者随机分为华法林治疗组（60例）和阿司匹林对照组（50例）,全部患者治疗前均查PT、NT、FIB、凝血酶原活动度及国际标准化比值（INR）。对照组给予口服阿司匹林片,治疗组给予口服华法林,维持INR2.0-2.5,随访2年,对比华法林与阿司匹林对非瓣膜性房颤患者脑卒中发病率的影响。结果阿司匹林对照组与华法林治疗组脑栓塞的发病率分别为16%、1.6%,阿司匹林组脑栓塞的发病率显著高于华法林组（P〈0.05）,两组出血率相比分别为6%和8.3%,差异无显著性（P〉0.05）。结论与阿司匹林相比,小剂量华法林更能有效降低老年患者脑卒中的发生,安全性好。     

房颤患者应用华法林抗凝治疗的临床体会

目的探讨房颤患者应用华法林抗凝治疗的疗效。方法用药前测INR1次,每天服用1次华法林,初始剂量2．5—3．0mg／d,应用华法林3d后复查INR,以后每天监测,根据INR调整剂量,每次0．5mg为调整单位。若INR连续2d稳定在2．0～3．0之间,每周检测2～3次,以后每周检测1次,1个月后改为每月检测1次,6个月后改为每2个月检测1次。若有出血等不良反应和栓塞并发症发生时即查血浆凝血酶原时间（PT）、INR。结果52例患者均得到随访,随访时间6个月～4年,华法林维持量为（3．0±0．05）mg／d。随访期间血栓栓塞并发症及不良反应脑栓塞2例,其中1例为既往发生过脑卒中的高血压患者;1例为瓣膜病患者;脑出血2例,为人工瓣膜患者,因咳嗽、咯痰、发热,在院外静点头孢曲松钠3．0g（1次／d）,1周后复查INR为8．45;黑便1例、血尿1例、球结膜出血2例、皮下出血2例、牙龈出血2例,经调整华法林剂量及对症处理后出血症状消失。结论心房颤动一旦确诊,又无抗凝禁忌,应常规给予华法林抗凝治疗,以尽早达到治疗效果。     

通心络胶囊治疗冠心病心绞痛的疗效观察

目的 观察通心络胶囊治疗冠心病心绞痛的疗效及副作用。方法 采用随机分组，治疗组83例给予通心络胶囊3粒，3次／d，对照组82例给予消心通10mg，3次/d。结果 治疗组临床疗效衣心电图改变均明显优于对照组（P＜0．05－0．01）。结论 通心绞胶囊治疗冠心病心绞痛疗效确切，无毒副作用。     

58例心房颤动患者口服华法林的临床分析

目的观察口服华法林治疗心房颤动的疗效。方法58例患者分为低强度组26例和中强度组32例,两组开始剂量均为2．5mg,然后根据INR值调整给药剂量。结果低强度组和中强度组INR稳定值分别为（1．72±0．18）和（2．31±0．27）,华法林的维持量分别为（2．37±0．48）mg／d和（2．98±0．33）mg／d,年出血率分别为3．0％和10．2％,年栓塞率分别为2．3％和0．7％。两组均无严重的出血并发症。结论口服华法林治疗心房颤动安全有效。     

华法林和阿司匹林对永久性房颤患者抗凝治疗的有效性及安全性观察

目的比较华法林和阿司匹林用于永久性房颤患者抗凝治疗的有效性及安全性。方法入选符合本研究标准的141例永久性房颤患者,随机分为两组,华法林组（治疗组）70例,以华法林2.5mg/d作为起始剂量,阿司匹林组（对照组）71例,阿司匹林100mg/d,早饭后即刻服用。结果治疗组发生出血3例（4.29%）,脑梗死2例（2.82%）,上腹不适1例（1.43%）。对照组发生出血2例（2.82%）,脑梗死13例（18.31%）,上腹不适15例（21.13%）。治疗组脑梗死、上腹不适的发生率低于对照组（P〈0.05）,两组间出血发生率无统计学差异（P〉0.05）。结论华法林抗凝治疗可明显减少栓塞事件及上腹部不适的发生率,INR维持在2.0～3.0之间,用药既有效又安全。     

观察华法林及阿司匹林分别对非瓣膜性心房颤动患者血栓栓塞的影响

目的观察华法林及阿司匹林对非瓣膜性心房颤动患者血栓栓塞事件的影响。方法80例非瓣膜性心房颤动患者分为华法林组及阿司匹林组,阿司匹林组每天服用阿司匹林100 mg,华法林组根据国际标准化比值(INR)调整华法林用量,随访时间为2 a。结果阿司匹林组死亡2例,1例为缺血性卒中,另1例为心力衰竭;华法林组1例为猝死。阿司匹林组发生栓塞事件共8例,出血并发症3例;华法林组发生栓塞事件共3例,出血并发症7例。结论华法林可明显降低非瓣膜性房颤患者血栓栓塞事件,但出血并发症稍增多,关键是要严密随访INR。     

Treatment patterns and real-world effectiveness of warfarin in nonvalvular atrial fibrillation within a managed care system

OBJECTIVE: To examine warfarin utilization and clinical effectiveness among patients with nonvalvular atrial fibrillation within usual clinical care in a managed care system.Research design and methods: A retrospective analysis of health care claims for an approximately four million member managed care organization was performed. Health plan members with a diagnosis of nonvalvular atrial fibrillation in calendar year 2000 were identified and stratified into two cohorts: Warfarin Therapy (newly initiating warfarin) or Warfarin Candidates (eligible for warfarin therapy according to the ACC/AHA/ESC Guidelines for the Management of Patients with Atrial Fibrillation, but did not receive warfarin). MEASUREMENTS: The occurrence of thromboembolism, ischemic stroke, and hemorrhage during a maximum 720-day follow-up were compared between cohorts, adjusting for age, gender, and other risk factors, using Cox regression. RESULTS: Among 12 539 subjects (mean age 78.0 +/- 8.8 years) with nonvalvular atrial fibrillation, 4895 (39.0%) initiated Warfarin Therapy and 7644 (61.0%) were Warfarin Candidates. Event occurrences among Warfarin Therapy vs. Warfarin Candidates were: ischemic stroke, 3.7% vs. 4.5%; any thromboembolism, 7.8% vs. 10.8%; and hemorrhage, 4.4% vs. 4.9%, respectively. Warfarin therapy was not associated with an increased risk for hemorrhage (hazard ratio [HR] = 0.97, 95% confidence interval [CI] = 0.82-1.15), while risks for ischemic stroke and any thromboembolism were significantly reduced, by 22% (HR = 0.78, 95% CI = 0.65-0.93) and 34% (HR = 0.66, 95% CI = 0.59-0.75), respectively. CONCLUSIONS: Within usual clinical care for the managed care population examined, warfarin remains underused despite current guidelines recommending its use in nearly all patients with nonvalvular atrial fibrillation. Although utilization of anticoagulation clinics and INR values attained were unknown in this study, the observed risk reductions for ischemic stroke and thromboembolism were lower than those achieved in clinical trials, while no increased risk for hemorrhage was observed. These findings suggest that warfarin is used conservatively, and dosed cautiously, diminishing the full potential benefit of anticoagulant therapy in patients with nonvalvular atrial fibrillation.     

Treatment patterns and real-world effectiveness of warfarin in nonvalvular atrial fibrillation within a managed care system

ABSTRACT

Objective: To examine warfarin utilization and clinical effectiveness among patients with nonvalvular atrial fibrillation within usual clinical care in a managed care system.

Research design and methods: A retrospective analysis of health care claims for an approximately four million member managed care organization was performed. Health plan members with a diagnosis of nonvalvular atrial fibrillation in calendar year 2000 were identified and stratified into two cohorts: Warfarin Therapy (newly initiating warfarin) or Warfarin Candidates (eligible for warfarin therapy according to the ACC/AHA/ESC Guidelines for the Management of Patients with Atrial Fibrillation, but did not receive warfarin).

Measurements: The occurrence of thromboembolism, ischemic stroke, and hemorrhage during a maximum 720‐day follow-up were compared between cohorts, adjusting for age, gender, and other risk factors, using Cox regression.

Results: Among 12?539 subjects (mean age 78.0 ± 8.8 years) with nonvalvular atrial fibrillation, 4895 (39.0%) initiated Warfarin Therapy and 7644 (61.0%) were Warfarin Candidates. Event occurrences among Warfarin Therapy vs. Warfarin Candidates were: ischemic stroke, 3.7% vs. 4.5%; any thromboembolism, 7.8% vs. 10.8%; and hemorrhage, 4.4% vs. 4.9%, respectively. Warfarin therapy was not associated with an increased risk for hemorrhage (hazard ratio [HR] = 0.97, 95% confidence interval [CI] = 0.82–1.15), while risks for ischemic stroke and any thromboembolism were significantly reduced, by 22% (HR = 0.78, 95% CI = 0.65–0.93) and 34% (HR = 0.66, 95% CI = 0.59–0.75), respectively.

Conclusions: Within usual clinical care for the managed care population examined, warfarin remains underused despite current guidelines recommending its use in nearly all patients with nonvalvular atrial fibrillation. Although utilization of anticoagulation clinics and INR values attained were unknown in this study, the observed risk reductions for ischemic stroke and thromboembolism were lower than those achieved in clinical trials, while no increased risk for hemorrhage was observed. These findings suggest that warfarin is used conservatively, and dosed cautiously, diminishing the full potential benefit of anticoagulant therapy in patients with nonvalvular atrial fibrillation.     

通心络胶囊加氟桂利嗪胶囊治疗偏头痛82例疗效观察

目的观察通心络胶囊加氟桂利嗪胶囊治疗偏头痛的临床疗效。方法将164例偏头痛患者随机分为两组。治疗组82例口服通心络胶囊3粒/次、每日3次,氟桂利嗪胶囊每晚口服10mg,对照组82例每晚口服氟桂利嗪胶囊10mg。两组均以4周为1个疗程。结果治疗组控制率为34.1%,总有效率为92.7%;对照组控制率为19.5%,总有效率为74.4%,两组比较差异有统计学意义(控制率比较:x2=4.47,P<0.05;总有效率比较:x2=9.97,P<0.05),两组都没有出现影响治疗的严重不良反应。结论氟桂利嗪胶囊治疗偏头痛有效,加用通心络胶囊则效果更佳,值得在临床上进一步推广使用。     

Use of herbal medicines by patients receiving warfarin.

BACKGROUND: Patients receiving warfarin therapy are discouraged from taking herbal medicines. Whether patients adhere to this advice and, if they do not, the types of products they use, are not known. OBJECTIVE: The objective of this observational study was to estimate the magnitude of use of herbal medicines among Chinese patients attending the Warfarin Clinic of the Prince of Wales Hospital in Hong Kong. METHODS: A medical officer interviewed all patients who attended the Warfarin Clinic during May 2001. Patients were asked about the use of herbal medicines in the preceding week. Demographic data, indication and duration of warfarin therapy, and International Normalised Ratio (INR) value at the time of the visit were also noted. RESULTS: Of 107 patients interviewed, 28 (26%) claimed to have taken herbal medicines during the week prior to the clinic visit. The users of herbal medicines had lower INR values than non-users (mean INR value 2.41 +/- 0.65 vs 2.75 +/- 0.65, p = 0.019), possibly because of a lower warfarin dosage (mean dosage 2.93 mg/day +/- 1.23 vs 3.34 mg/day +/- 1.45; p = 0.185) and because a smaller proportion of such patients had heart valve replacement (21% vs 39%, p = 0.141). 'Herbal soup' (soup made at home from vegetables, meat and certain herbs for consumption with the main meals) and 'cool tea' (herbal decoction for the treatment of 'endogenous heat') were the most popular and were taken by 12 (11%) and 11 (10%) patients, respectively. Four patients took proprietary medicines each containing between one and three different herbs that could potentially enhance or antagonise the effects of warfarin. None of the patients in this study showed any evidence of thromboembolism or bleeding on the day of clinic visit. CONCLUSION: Among Chinese patients treated with warfarin at a Hong Kong clinic, the use of herbal medicines was relatively common. Healthcare professionals play an important role in educating the patients and updating the list of herbal medicines that should be avoided by patients taking warfarin.     

Warfarin and aspirin give more benefit than aspirin alone but also more bleeding after myocardial infarction

The anticoagulant, warfarin, and the antiplatelet agent, aspirin, have been shown to have similar benefits after myocardial infarction. As these agents have different mechanisms of action, the beneficial effects of warfarin and aspirin may be additive after myocardial infarction. In the Warfarin, Aspirin, Reinfarction Study (WARIS II), the main outcome was a composite of death, non-fatal reinfarction or thromboembolic stroke, whichever came first over 4 years. Compared to aspirin alone (160 mg/day), the risk reduction was 19% (p = 0.03) with warfarin alone (INR of 2.8 IU) and 29% (p = 0.001) with the combination of aspirin and warfarin (aspirin, 75 mg/day; warfarin, INR of 2.2 IU). This difference in the first event with warfarin alone or the combination, represented a reduction in reinfarction and thromboembolic stroke rather than death. For reinfarction, compared to aspirin alone (117 of 1206), there was a reduction with warfarin alone (90 of 1216) and a further reduction with the combination (69 of 1208). For thromboembolic stroke, compared to aspirin (32 of 1206), there were similar reductions with warfarin and the combination. There were more major and minor bleeding in the warfarin groups than the aspirin group, with major bleeding occurring in 8, 33 and 28 patients taking aspirin, warfarin and aspirin and warfarin, respectively. In conclusion, as compared with aspirin alone, therapy with moderate-intensity warfarin combined with aspirin and high-intensity warfarin alone, resulted in a reduced risk of reinfarction and ischemic stroke but a higher risk of bleeding.     

药物相互作用致心房颤动患者INR异常升高的病例分析及文献复习

患者女性,85岁,因房颤长期服用华法林,国际标准化比值(INR)1.6-2.5。患者因咽痛服用头孢氨苄片3d,停用2d后INR升至11.72,伴右上臂片状瘀斑。次日停用华法林,给予静脉滴注10mg维生素K1,INR降至2.6。2d后重启华法林治疗,INR1.6-2.5。应用华法林时如增加合并用药,要密切监测INR及出血情况,重视华法林的药物相互作用。患者教育对华法林的用药安全十分重要。     

New pharmacologic approaches to prevent thromboembolism in patients with atrial fibrillation

Atrial fibrillation (AF) is associated with a 6 fold increased risk for ischemic stroke. Observational studies suggest that one in four to five strokes is due to AF. Depending on the risk profile of an individual patient, the yearly risk for ischemic stroke is between 2% and 14%. AF is accompanied by an increased propensity for atrial clot formation due to a combination of decreased atrial blood flow, increased activity of the platelet/plasmatic coagulation system and prothrombotic changes at the atrial endocardium. This review summarizes the current guidelines for thromboembolic prevention in patients with AF. In many cases, continuous oral anticoagulation therapy (OAT) with vitamin K antagonists (VitKAs) is indicated if AF is accompanied by more than one additional risk factor for thromboembolic complications. However, therapeutic range of VitKAs (Phenprocoumon, Warfarin, and others), the most commonly used oral anticoagulants, is narrow and their use requires regular anticoagulation monitoring. Possibly due to these limitations, about one third of eligible patients are not treated with VitKAs. Furthermore, in many treated patients OAT is not well controlled. Thus, in clinical practice anticoagulation therapy in AF is suboptimal. Therefore, new and more convenient pharmacologic approaches to prevent thromboembolism with i.e. direct thrombin inhibitors (DTI), synthetic polysaccharides (factor Xa Inhibitors), and others are discussed, and their possible future role in the treatment of AF is evaluated.