非瓣膜病房颤患者华法林抗凝治疗的现状

目的了解非瓣膜病心房颤动(房颤)患者口服华法林抗凝治疗状况及其影响因素。方法收集2012年6月至2014年6月在我科住院的非瓣膜病房颤患者一般情况、疾病特征、合并疾病及抗凝治疗等,并对患者进行CHA_2DS_2-VAS_C风险评分,评估房颤患者的抗凝治疗现状,并对影响华法林使用的因素进行多因素分析。结果在入选的499例房颤人群中,有77例(15.4%)接受华法林治疗,其中慢性心力衰竭史、永久性房颤、缺血性卒中/一过性脑缺血发作史,CHA_2DS_2-VAS_C风险评分高者更多使用华法林治疗,合并冠心病的房颤患者更多选用抗血小板药物治疗。多因素回归分析显示,年龄、冠心病、心力衰竭病史都是影响华法林使用的因素。结论非瓣膜病房颤患者使用华法林抗凝治疗严重不足,未能严格按照CHA_2DS_2-VAS_C风险评分进行正规抗凝。     

非瓣膜性房颤患者华法林抗凝治疗现况研究

目的探讨非瓣膜性心房颤动患者规范化使用华法林抗凝治疗的现状,分析影响规范化抗凝治疗的因素,进一步提高规范化抗凝治疗的治疗率。方法选取2013-01~2015-12收治的510例非瓣膜性房颤患者的临床资料,采用CHADS2评分法筛选出符合要求使用华法林治疗的患者291例进行回顾性分析,评价其规范化抗凝治疗情况。结果 CHADS2评分≥2分符合要求使用华法林的291例患者中,规范化抗凝治疗只有61例(20.9%)。结论应加强对华法林抗凝治疗效果的认识,提高房颤患者规范化抗凝治疗的控制率和治疗率。     

老年心房颤动患者华法林抗凝治疗剂量达标情况及安全性

目的探讨老年心房颤动患者使用较低剂量华法林抗凝治疗的达标情况及安全性。方法选择80例老年房颤患者,分为持续性(n=39)及永久性(n=41)两组,根据房颤指南分为中危(n=42)及高危(n=38)两组,分析使用华法林抗凝治疗预防血栓栓塞事件的剂量达标情况。结果房颤治疗第1周与第2周比较,达标例数及总达标率均有显著差异(P0.05),而剂量达标时的国际标准化比值(INR),第1周与第2周相比无显著差异(P0.05)。结论老年房颤患者使用华法林抗凝治疗,在较低剂量下即可获得较满意的疗效,只要严格掌握适应证及严密监测INR,使用华法林抗凝治疗是安全可靠的。     

住院心房颤动患者的抗凝治疗

目的调查持续性心房颤动(房颤)患者临床特征、抗凝治疗及抗凝强度监测情况。方法回顾性分析2010年1月至2013年12月在广西医科大学第一附属医院诊治的来自广西各地的房颤患者的临床特征、抗凝治疗率、达标率。结果 296例持续性房颤患者中88例(29.72%)在门诊治疗时使用了华法林抗凝,然而达标仅34例(达标率38.64%)。瓣膜病房颤的抗凝治疗率显著高于非瓣膜病房颤(NVAF)(P0.01),但两者的抗凝达标率差异无统计学意义(P0.05)。NVAF患者合并有脑卒中、血栓栓塞、外周动脉疾病等情况时华法林抗凝治疗率显著高于没有上述情况患者(P0.05)。结论广西地区持续性房颤患者华法林抗凝治疗率及达标率低。     

贵州省铜仁市10家县级综合医院心房颤动患者华法林抗凝治疗调查

目的了解贵州省铜仁市10家县级综合医院心房颤动患者华法林抗凝治疗现状及存在的问题,探讨基层医院合理、有效、安全使用华法林的应对策略。方法根据调查目的设计方案,查阅病历资料,并对现场医生进行问卷调查,回顾性分析2013年贵州省铜仁市10家县级综合医院心房颤动患者华法林使用情况。结果 10家县级综合医院共收治115例房颤住院患者,其中2家医院对4例患者应用了华法林抗凝治疗,华法林使用率3.48%。所有接受华法林抗凝治疗患者长期进行国际标准化比值(INR)监测,INR(1.5~2.0)保持在低水平状态。结论 10家县级综合医院心房颤动患者华法林抗凝治疗率极低,华法林应用不规范、不合理问题较一些文献报道更突出。应加大华法林的推广应用,促进抗凝剂的合理使用,使更多的患者享受到抗凝治疗带来的好处。     

上海某社区212例心房颤动患者抗凝现状

目的调查上海华泾社区心房颤动(房颤)患者的抗凝现状,以提高社区对房颤患者抗凝治疗的重视。方法调查2009年3月至2019年3月212例华泾社区房颤住院患者的病史,内容包括一般情况、并发疾病和抗凝方案,按照CHADS2评分分析房颤患者的抗凝现状。结果 212例房颤患者并发疾病前3位是冠状动脉粥样硬化性心脏病(冠心病)(92.92%)、原发性高血压(高血压)(68.87%))和糖尿病(27.36%)。所有患者的总体抗凝率为4.24%,抗凝药物皆为华法林,抗血小板率为64.15%。非脑卒中组华法林抗凝率明显高于脑卒中组,差异有统计学意义(10.16%vs. 1.96%,P0.05)。结论目前社区房颤患者抗凝比例低,需加强抗凝治疗。     

华法林治疗风心病房颤的抗凝疗效分析

目的探讨华法林治疗风心病房颤的抗凝疗效。方法将2018年7月到2019年7月我院91例风心病房颤患者作为研究对象,运用随机数字表法随机将其分为对照组(n=45)与试验组(n=46),对照组施以阿司匹林治疗,试验组施以华法林治疗,观察两组患者的临床治疗总有效率情况、脑血管意外发生情况及不良反应发生情况。结果试验组的临床治疗总有效率明显较高,脑血管意外发生率与不良反应发生率明显较低,两组相比差异显著(P<0.05)。结论华法林治疗风心病房颤的抗凝具有显著的临床疗效。     

高龄非瓣膜病性房颤患者长期运用华法林抗凝治疗的疗效与安全性分析

目的分析高龄非瓣膜病性房颤患者长期运用华法林抗凝治疗的疗效与安全性。方法选取2015年4月~2016年4月经我院确诊的高龄非瓣膜病性房颤患者60例(75~86岁)。随机分为对照组(给予阿司匹林治疗方法)和研究组(给予华法林抗凝治疗方法),各30例。对两组的终点事件发生率以及出血率进行分析和对比。结果研究组终点事件发生率(脑卒中发生率、短暂性脑缺血发生率、死亡率)均低于对照组,差异有统计学意义(P0.05)。结论对高龄非瓣膜病性房颤患者采用华法林抗凝治疗,效果显著,安全可靠,值得临床推广使用。     

心房颤动患者经导管射频消融术后的抗凝治疗

心房颤动(简称房颤)患者需要抗凝治疗,然而对于经导管射频消融术后的房颤患者,其抗凝策略尚存在争议。华法林可以降低患者的血栓栓塞发生率,也会相应的增加出血风险。对于中低危患者目前倾向于阿司匹林替代华法林用于术后的抗凝治疗,而目前对于高危患者虽有新的争议,但是仍倾向于使用华法林。新的抗凝药物的上市可能取代华法林。     

我院226例房颤患者抗凝应用情况调查分析

目的了解我院心血管内科房颤住院患者的抗凝情况,进一步规范抗凝治疗。方法采用回顾性分析方法,调取我院2016年1月-2016年12月心血管内科住院的房颤患者病例资料,记录性别、年龄、主要诊断、合并疾病、CHA2DS2-VASc评分、INR值、华法林剂量、新型口服抗凝剂(达比加群酯、利伐沙班)、阿司匹林、氯吡格雷使用情况,进行汇总分析,并评价其抗凝治疗的规范性。结果房颤患者以老年患者为主,男性多于女性,房颤类型以非瓣膜性房颤为主;CHA2DS2-VASC评分为0分的AF患者中14.28%采用NOAC抗凝治疗;CHA2DS2-VASC评分为1分的AF患者中68.97%接受华法林抗凝治疗;CHA2DS2-VASC评分≥2分的AF患者中64.96%接受华法林治疗、8.67%采用NOAC治疗。而瓣膜性房颤患者中92.45%接受华法林抗凝治疗。结论我院心内科房颤患者抗凝基本符合指南要求,但是还存在一些抗凝不规范的情况,需要进一步规范抗凝治疗。     

非瓣膜性心房颤动应用新型口服抗凝药依从性分析

目的探讨非瓣膜性心房颤动(房颤)患者应用新型口服抗凝药(new oral anticoagulants,NOACs)的依从性及其主要影响因素。方法连续入选2018年1月1日至2018年12月31日于徐州医科大学附属医院心内科住院并行保守抗凝治疗的非瓣膜性房颤性患者272例,根据应用抗凝药种类不同分为华法林组96例和新型口服抗凝药组176例,出院后进行电话随访,比较两组患者抗凝依从性和各自停药原因及影响因素。结果华法林组与NOACs组患者在性别分布、心功能分级、合并疾病方面无统计学差异。平均随访(8.80±3.51)月,NOACs组停药率显著高于华法林组(57.39%vs.22.92%,P<0.001)。对房颤疾病本身及其危害认识不足是两组患者停药的共同主要原因,经济因素、购买因素、出血因素、对疾病缺乏认识对两组患者停用抗凝药均具有显著影响。结论目前新型口服抗凝药服药依从性仍较低,多种因素影响房颤抗凝,其中对房颤缺乏正确认识是导致患者停药的主要原因。     

老年非瓣膜病性心房纤颤患者抗血栓治疗现状分析

目的分析空军总医院老年非瓣膜病性心房纤颤（NVAF）患者抗血栓药物治疗现状及未抗凝治疗的原因。方法调查老年NVAF患者109例,对其病因、血栓栓塞危险因素、抗血栓药物应用情况及未应用华法林抗凝治疗原因进行分析。应用CHADS卒中风险评分表对NVAF患者进行血栓栓塞危险评估。结果91.6%患者接受了抗血栓治疗。符合抗凝治疗指征患者68例,仅38.2%接受了华法林治疗,57.4%进行了抗血小板治疗阿司匹林剂量为（87±15）mg/d,4.4%未进行任何抗血栓治疗。而其中NVAF呈阵发性者仅5.0%应用了华法林抗凝治疗。未抗凝治疗者54例,其中存在抗凝禁忌证12例（15.0%）;严重出血而停用1例（1.3%）,不能凝血监测2例（2.5%）;担心出血拒绝8例（10.0%）;阵发性心房纤颤未抗凝治疗20例（25.0%）;冠脉支架术后双重抗血小板治疗而未抗凝治疗3例（3.75%）;原因不明9例（11.3%）。结论老年NVAF患者抗血栓治疗中华法林应用率低,而且阵发性心房纤颤的华法林应用率更低,抗血小板治疗中阿司匹林剂量不足。     

Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians' fears often unfounded

BACKGROUND: Many studies have documented the underuse of anticoagulant (ie, warfarin sodium) therapy as stroke prophylaxis in older persons with atrial fibrillation. Failure to prescribe anticoagulant agents to these patients is often due to physicians' perceiving the risk of major bleeding as unacceptably high because of the presence of such clinical risk factors as hypertension, falls, a history of gastrointestinal tract bleeding, and lack of assurance about compliance. OBJECTIVES: To critically appraise whether the presence of additional clinical factors that increase the risk of bleeding affects the chance of anticoagulant-related hemorrhage, and to develop an approach to the use of anticoagulant agents in older patients with atrial fibrillation who have any of these factors. METHODS: Systematic MEDLINE literature search from January 1966 to March 2002. RESULTS: Many of the factors that are purported to be barriers to anticoagulant therapy in older persons with atrial fibrillation probably should not influence the choice of stroke prophylaxis in these patients. These include previous episodes of upper gastrointestinal tract bleeding, predisposition to falling, and old age in itself. For some other factors, such as alcoholism, participation in activities that predispose to trauma, the presence of a bleeding diathesis or thrombocytopenia, and noncompliance with monitoring, there is little or conflicting evidence about their effect on anticoagulant-related bleeding. However, they should be considered in the clinical decision-making process. CONCLUSIONS: For many older patients with atrial fibrillation, physicians' fears of the risk of bleeding in association with anticoagulant therapy are often exaggerated and unfounded. Therefore, the salient issue in selecting older patients with atrial fibrillation for anticoagulation is accurately estimating their stroke risk, with bleeding risk during anticoagulation being a lesser issue, relevant to only a few patients.     

Management of atrial fibrillation: discrepancy between guideline recommendations and actual practice exposes patients to risk for complications.

AIMS: To assess compliance to guidelines in the management of patients with atrial fibrillation. METHODS AND RESULTS: A total of 728 questionnaires were mailed to physicians with the intention of studying 'theoretical' compliance to practice guidelines. A retrospective evaluation of 200 records from consecutive patients hospitalized with atrial fibrillation was performed in order to verify 'actual' compliance to guidelines. The response rate to the questionnaires was 68%. More than 94% of the physicians stated that patients with risk factors for thromboembolic complications and chronic atrial fibrillation should receive long-term warfarin treatment. Of evaluated records, 108 patients were in chronic atrial fibrillation with at least one risk factor for stroke, and with no known contraindication to warfarin. In this group, only 40% received warfarin. Moreover, several other discrepancies were detected as regards the use of antiarrhythmic therapy. CONCLUSION: This study reveals a clear discrepancy between recommendations in guidelines and actual practice in patients with atrial fibrillation. The most important finding was a significant under use of thromboembolic prophylaxis in patients at high risk for such events. Implementation and the study of adherence to management guidelines on atrial fibrillation need to be carefully reviewed by surveys of actual clinical practice in order to establish reasonable therapeutic quality.     

Factors Affecting the Maintenance Stable Warfarin Dosage in Hong Kong Chinese Patients

Background: Multiple factors can affect the anticoagulation effect of warfarin. The objective of this study was to determine the relationship between different clinical factors and outcomes of warfarin therapy in Hong Kong Chinese patients.Methods: The study was conducted at the anticoagulation clinic of the Prince of Wales Hospital from 1 April to 31 December 2003. Clinical data collected included demographics, indications of warfarin, dietary vitamin K consumption, and drug-drug interactions. Blood samples were obtained for the genetic polymorphism analysis of CYP 2C9. Linear and multiple regression analysis were used for statistical analysis to determine the correlation between variables and the importance of various factors as the determinants of warfarin dosage requirement.Results: A total of 63 patients were recruited. The mean warfarin dosage was 3.30 ± 2.23 mg/day. The warfarin dosage ranged from 0.75 to 12 mg/day. The mean age was 59 ± 14 years old. Age, dietary vitamin K consumption, chronic heart failure, atrial fibrillation, hypertension, smoking and drinking status were found to be factors statistically significant affecting warfarin dosage. We detected no single nucleotide polymorphism in CYP 2C9 exon 4.Conclusion: Age, dietary vitamin K consumption, warfarin indication for atrial fibrillation, co-morbid with CHF, smoking and drinking status were found to be the factors that affected the warfarin requirement in Hong Kong Chinese patients. However, the genetic polymorphism in exon 4 of CYP 2C9 may not be associated with the warfarin sensitivity in this patient population.     

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。     

华法林周剂量给药策略治疗非瓣膜性心房颤动患者的疗效及可行性分析

目的:对于非瓣膜性心房颤动患者,评估两种不同华法林给药策略的抗凝疗效。方法:选择我院2015年1月至2019年1月收治的有抗凝指征、首次给药1周后国际标准化比值(INR)未达标的163例非瓣膜性心房颤动患者,随机分为周剂量组(n=82)和日剂量组(n=81)。周剂量组按每周总剂量调整华法林日剂量(每日剂量可不同),日剂量组按每日固定剂量给予华法林。研究主要终点包括两组INR达到稳定时间(连续3次INR达标≥2次)、INR在目标范围时间的百分比(TTR)、TTR达标率、亚治疗(INR<1.5)和超治疗(INR>4)INR百分比,次要终点为随访期间血栓栓塞及出血事件的发生情况。结果:周剂量组和日剂量组INR稳定时每日平均剂量差异无统计学意义[(2.5±1.0)mg vs(2.7±1.1)mg,P=0.349]。周剂量组INR达到稳定的平均时间显著短于日剂量组[(11.7±11.9)周vs(19.3±19.1)周,P<0.01]。周剂量组平均TTR[(55.6%±26.0%)vs(45.0%±25.5%),P<0.01]、TTR达标率(45.1%vs 27.2%,P<0.05)均显著高于日剂量组。周剂量组亚治疗(18.3%vs 23.1%,P<0.01)和超治疗INR百分比(2.0%vs 3.0%,P=0.100)均低于日剂量组,但后者差异无统计学意义。周剂量组血栓栓塞事件(1.2%vs 9.9%,P<0.05)、总体不良事件(3.7%vs 17.3%,P<0.01)的发生率显著低于日剂量组,出血事件(2.4%vs 7.4%,P=0.269)虽也较日剂量组低,但差异无统计学意义。结论:对于非瓣膜性心房颤动患者,与华法林每日固定剂量给药策略相比,周剂量给药策略能显著提高抗凝治疗的疗效,更快地达到目标INR,降低不良事件的发生率。     

Anticoagulant use for atrial fibrillation in the elderly

OBJECTIVES: To determine the influence of advanced age on anticoagulant use in subjects with atrial fibrillation and to explore the extent to which risk factors for stroke and contraindications to anticoagulant therapy predict subsequent use. DESIGN: Retrospective cohort study. SETTING: The Veterans Affairs Boston Healthcare System. PARTICIPANTS: A total of 2,217 subjects with nonvalvular atrial fibrillation. MEASUREMENTS: Administrative databases were use to identify subject's age, anticoagulant use, and the presence of a diagnosis of atrial fibrillation, cerebrovascular accident, hypertension, diabetes mellitus, congestive heart failure, or gastrointestinal or cerebral hemorrhage. RESULTS: Unadjusted analysis showed no difference in warfarin use between those aged 75 and older and younger subjects regardless of the presence (33.9% vs 35.7%, P=.37) or absence (33.4% vs 34.7%, P=.58) of contraindications to anticoagulant therapy. Multivariate modeling demonstrated a 14% reduction (95% confidence interval (CI)=4-22%) in anticoagulant use with each advancing decade of life. Intracranial hemorrhage was a significant deterrent (odds ratio (OR)=0.27 95% CI=0.06-0.85). History of hypertension (OR=2.90, 95% CI=2.15-3.89), congestive heart failure (OR=1.70, 95% CI=1.41-2.04), and cerebrovascular accident (OR=1.54, 95% CI=1.25-1.89) were significant independent predictors for anticoagulant use. CONCLUSION: Despite consensus guidelines to treat all atrial fibrillation patients aged 75 and older with anticoagulants, advancing age was found to be a deterrent to warfarin use. Better estimates of the risk:benefit ratio for oral anticoagulant therapy in older patients with atrial fibrillation are needed to optimize decision-making.     

875例老年心房颤动患者抗血栓治疗现状分析

目的了解老年心房颤动(房颤)患者抗血栓治疗现状,为老年房颤的治疗提供参考。方法选择资料完整的老年房颤患者875例,将其中济南军区总医院的445例房颤患者按年龄分为60～74岁158例,75～80岁118例,81～84岁11 2例,≥85岁57例。回顾性分析所有患者的一般情况、合并疾病、房颤分类及用药情况。结果所有阵发性房颤治疗以药物复律为主,占61.4%,所有持续性和永久性房颤治疗以控制心室率为主,占80.1%,抗血栓治疗以阿司匹林为主,占77.7%,华法林占1 4.5%。与60～74岁比较,其他年龄段患者建议服用华法林治疗比例明显升高(P<0.05),与≥80岁比较,75～80岁、81～84岁患者实际服用华法林治疗比例明显升高(P<0.05)。结论阵发性房颤使用胺碘酮最多,抗血栓治疗阿司匹林使用普遍,基层医院华法林使用率较低。     

非瓣膜病房颤患者VKORC1与CYP2C9基因多态性华法林抗凝剂量模型临床疗效评价

目的：验证非瓣膜病房颤患者运用VKORC1与CYP2C9基因多态性华法林抗凝剂量模型的有效性与可行性,以探求华法林个体化临床应用,缩短达标时间,提高该药使用率与依从性。方法：选择沈阳医学院附属第二医院心血管内科住院治疗非瓣膜性房颤患者分为模型组与经验组,两组各60例,记录基线资料,并提取空腹静脉血检测VKORC1-1639与CYP2C9基因多态性。模型组患者日剂量根据既定公式计算所得给予华法林片,经验组根据医师临床用药经验及体重给予起始剂量。随访6个月,记录达稳定剂量时间,INR达标时间,计算INR在治疗目标范围内的时间百分比(TTR)。结果：两组需要服用华法林进行抗凝治疗的患者基线指标比较差异无统计学意义 (P>0.05)。模型组预测剂量与实际剂量较为接近,有63%的患者未调整剂量,该比例明显高于经验组,达稳态维持剂量时间亦短于经验组,同时模型组INR达标时间较短。此外模型组TTR＞60%患者为39例(53.4%),而经验组为28例(37.3%)。结论：利用针对中国人群的基于VKORC1与CYP2C9基因多态性华法林抗凝剂量模型对非瓣膜病房颤患者进行华法林起始及稳定剂量预测,模型的预测准确性可达60%以上。该模型具有一定的临床实用价值。