Analysis of Antithrombotic Therapy After Cardioembolic Stroke Due to Atrial Fibrillation or Flutter

Background:

Guidelines recommend that all patients with atrial fibrillation and a history of ischemic stroke should receive an anticoagulant. Prior analyses show that warfarin is underutilized in most populations.

Objective:

To examine the use of antithrombotic and anticoagulant therapy in patients with atrial fibrillation or flutter during the index hospitalization for acute, ischemic stroke.

Methods:

Retrospective electronic medical record review of 200 patients treated at a tertiary care hospital with a primary ICD-9 code for ischemic stroke and a secondary ICD-9 code for atrial fibrillation or flutter. Exclusion criteria were active bleeding, pregnancy, age less than 18, pre-existing warfarin allergy, or dabigatran use.

Results:

Fifty-two percent of patients received at least one dose of warfarin during the index hospitalization. There was no relationship between CHADS₂ score and likelihood of receiving warfarin (P > .05). There was no significant difference in adverse event rate in patients receiving warfarin compared to those receiving aspirin (3.8% vs 9.1%; P = .14), but the rate of hemorrhagic transformation was lower in patients receiving warfarin (1% vs 7%; P = .03). The composite of hemorrhagic stroke or hemorrhagic transformation was significantly lower in patients receiving bridging therapy (0% vs 11%; P = .03). Sixteen patients were readmitted for stroke within 3 months of discharge. Ten were readmitted for ischemic stroke, 3 for hemorrhagic stroke or hemorrhagic transformation, and 3 for systemic bleeding. Ten patients (62.5%) were receiving warfarin at readmission, but only one of these patients had a therapeutic INR.

Conclusions:

Warfarin was underutilized as secondary stroke prophylaxis in these high-risk patients. Bridging therapy appeared to be safe and was not associated with an increase in adverse events.     

心房纤颤伴高血压、高脂血症患者抗栓治疗分析附病例报告

目的 探讨临床诊疗中心房纤颤伴发其他疾病的抗凝药物治疗方案的安全性、合理性及有效性,促进临床合理用药.方法 临床药师选取1例临床上诊断为心房纤颤伴高血压、高脂血症患者,认真对患者进行药学查房,监护患者用药经过,并对所用抗栓药物进行合理性、有效性分析.结果 依据危险分层及病情评估,患者住院期间抗栓治疗方案欠妥当.结论为保证患者得到安全、合理、有效地治疗,临床诊疗及药物地选择上应当综合评估,制定个体化治疗方案.     

Anticoagulation Therapy for Patients with Non-Valvular Atrial Fibrillation

Background: Anticoagulation in patients with atrial fibrillation (AF) is challenging because stroke-risk reduction must be balanced against increased bleeding risk. Objective: We developed a decision model integrating both stroke and bleeding risk schemes to guide optimal use of anticoagulation in AF, and compared model recommendations with warfarin use in a real-world database. Methods: A Markov model based on demographics, CHADS₂ (Congestive Heart Failure, Hypertension, Age of 75 years and greater, Diabetes Mellitus and History of Stroke) stroke and ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleed risk scores, and anticoagulation treatment effects from clinical trials simulated health state transitions for recently diagnosed AF patients. The model recommended the treatment with greater quality-adjusted life expectancy. Model recommendations were contrasted with actual warfarin use recorded in the Thomson Reuters MarketScan database (N=64 946). Results: 74.8% (n = 48 548) of the Marketscan AF cohort had CHADS₂ ≥1, of whom 14.3% had moderate/high (≥4) ATRIA bleeding risk. While the model recommended warfarin for almost all patients with CHADS₂ ≥1 who are at low bleeding risk, it recommended warfarin for fewer patients as bleeding risk increased. Of the 44 611 patients recommended warfarin, 63.4% of patients were considered warfarin exposed (concordant with model recommendation), and of the 20 335 patients recommended aspirin (ace-tylsalicylic acid), 59.7% received warfarin (discordant with model recommendations). Actual warfarin use decreased modestly with higher stroke risk (p< 0.0001) and with higher bleeding risk (p< 0.0001). Conclusion: High discordance between actual warfarin use and model recommendations suggests that anticoagulation decisions are not based on systematic evaluation of stroke and bleeding risks. Model-based clinical decision aids may improve oral anticoagulation decisions by more systematically weighing bleed and stroke risk.     

对380例非瓣膜病性房颤抗栓治疗的调查与分析

收集2014年1月至2016年12月间入住苏州大学附属第一医院的380例非瓣膜病性房颤（NVAF）患者的病历资料。通过卒中和出血风险评估制定抗栓治疗方案,作基因型检测和国际标准化比值（INR）监测等,并对未抗凝治疗的原因进行分析。结果显示,NVAF患者的总体抗凝率为61.84%,其中CHA2DS2-VASc评分≥2分的抗凝率为63.33%,在289例抗栓治疗的患者中,有59.52%选择华法林抗凝,21.80%选择达比加群酯抗凝;172例华法林抗凝的患者出院时INR的达标率为22.09%,行CYP2C9和VKORC1基因型检测的患者其INR达标率（40.74%）明显高于未检测者。     

1例动脉源性急性缺血性脑卒中合并非瓣膜性房颤的抗栓方案的分析

临床药师参与1例动脉源性急性缺血性脑卒中合并非瓣膜性房颤患者抗栓治疗的全过程。临床药师对患者血栓风险和出血风险进行评估;参与制定抗栓治疗方案;对患者进行药学监护与用药教育。临床药师的参与,提高了用药的准确性和治疗效果,保障了患者用药安全有效。     

华法林在低栓塞风险的心房颤动患者射频消融术后的应用

目的探讨消融治疗获得成功的持续性心房颤动患者,特别是栓塞风险低的个体,术后是否需要继续应用华法林抗凝治疗。方法入选低危栓塞风险的持续性心房颤动患者107例,射频消融术后随机分为华法林治疗组(55例)和非华法林组(52例),华法林治疗组患者术后服用华法林治疗至少3个月,抗凝治疗强度为INR2.0～3.0;非华法林组只服用阿司匹林,每日100mg。所有患者术后均进行随访,观察比较两组患者血栓栓塞和出血事件发生率的差异。结果所有患者均成功完成射频消融术,即刻成功率为100%。两组患者术中均未发生栓塞或出血事件。随访6～18个月,华法林组发生血栓栓塞事件2例(3.6%),非华法林组发生2例(3.7%),两组患者栓塞发生率无统计学差异,P>0.1。华法林组有3例(5.5%)出血事件,非华法林组无出血事件发生。结论对于射频消融取得成功的低危心房颤动患者,可以考虑不应用华法林抗凝,而只服用阿司匹林。     

高龄冠心病合并心房颤动患者不同抗栓治疗方案的疗效及安全性

目的观察高龄冠心病合并心房颤动患者不同抗栓治疗方案的疗效及安全性疗效。方法我院2018年2月至2019年2月收治的66例高龄冠心病合并心房颤动患者为本次研究对象,按照抗栓治疗方案不同将所有患者分为对照组(33例,阿司匹林、氯吡格雷抗栓治疗)与试验组(33例,阿司匹林、氯吡格雷联合华法林抗栓治疗),比较两组患者疗效。结果给药3个疗程后,试验组患者活化部分凝血活酶时间(APTT)、凝血酶时间(TT)以及D二聚体(D-D)等炎症指标以及C反应蛋白(CRP)、肿瘤坏死因子α(TNF-α)、白细胞介素6(IL-6)等炎症指标均优于对照组,P <0.05;试验组患者不良反应发生率(6.06%)明显低于对照组(18.18%),P <0.05。结论高龄冠心病合并心房颤动患者应用阿司匹林联合华法林抗栓治疗,效果明显优于单一阿司匹林抗栓的治疗效果。     

Role of Irbesartan in Prevention of Post-Coronary Artery Bypass Graft Atrial Fibrillation

Background and Objective

Atrial fibrillation (AF) is a common complication of cardiothoracic surgery (CTS). Existing evidence about the potential protective role of angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) for post-CTS AF has been limited and conflicting. In this single-blind, open-label, randomized prospective pilot study, we evaluated the potential protective role of irbesartan (an ARB) in post-coronary artery bypass graft (CABG) AF.

Methods

A total of 100 consecutive patients undergoing CABG were randomly assigned to irbesartan (n = 50) versus no irbesartan (n = 50) for 5 days prior to the scheduled surgery. Data were collected for imaging studies, laboratory values, and peri-operative details. Patients were monitored post-operatively for in-hospital AF episodes. Unadjusted and adjusted logistic regression analysis was performed to assess the effect of irbesartan on the incidence of post-CABG AF.

Results

A total of 14 patients developed AF during their post-operative hospital stay. The incidence of AF in patients who received irbesartan was 6% (n = 3) compared with 22% (n = 11) in patients who did not receive irbesartan (p = 0.021). Univariate logistic regression analysis identified irbesartan and age as statistically significant variables. An adjusted multivariate logistic model identified irbesartan as an important protective factor against development of post-CABG AF (adjusted odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04, 0.94; p = 0.04). Increasing age (adjusted OR 1.09, 95% CI 1.01, 1.17; p = 0.03) was also identified as an independent risk factor for development of post-CABG AF.

Conclusion

Pretreatment with irbesartan tends to have a significant protective effect against the occurrence of AF during the post-operative period in patients undergoing CABG.     

缬沙坦对高血压病并阵发性房颤患者房颤的影响

目的 探讨缬沙坦对高血压并阵发性心房颤动患者房颤的疗效.方法 选取本院156名高血压合并阵发性房颤患者随机分成缬沙坦治疗组与氨氯地平对照组,治疗组口服缬沙坦80～160 mg/d,对照组口服用氨氯地平5～10 mg/d,观察12 m,记录治疗前后的血压、左房内径(LAD)及房颤发作情况,使用统计学方法 比较12 m后维持窦性心律的情况与左心房大小等参数变化.结果 治疗组维持窦性心律的情况以及改善左心房功能的疗效优于对照组,两组差异有统计学意义(P＜0.05).结论 缬沙坦对高血压并阵发性心房颤动患者的维持窦性心律及改善左心房功能有一定的帮助.     

我院非瓣膜性房颤患者抗凝治疗现状调查分析

目的:了解非瓣膜性心房颤动患者抗凝治疗现状,为其规范化抗凝治疗提供参考。方法:选取我院2015年7月-2016年6月非瓣膜性心房颤动患者1 056例,按照《2012年欧洲心脏病学会(ESC)心房颤动治疗指南》,对患者进行血栓栓塞危险和出血风险评估,并评价其抗凝治疗规范化情况。结果:血栓栓塞危险评分≥1的例数为1 028例,占总非瓣膜性心房颤动患者的97.3%。763例患者接受抗血栓治疗,而服用华法林抗凝治疗的仅有139例。服用华法林患者出院前凝血酶原时间的国际标准化比值达标率仅30.9%。结论:非瓣膜性心房颤动患者抗凝治疗现状不容乐观,应采取有效的干预措施,提高心房颤动患者抗凝治疗规范化程度。     

一例房颤合并冠心病患者初始抗栓治疗策略及文献复习

目的 探讨房颤伴急性冠脉综合征的抗栓治疗策略。方法 1例46岁房颤合并冠心病的男性患者,房颤卒中风险低危,入院期间未给予抗凝治疗,后出现急性脑梗塞。通过提阅部分指南及文献,分析CHA₂DS₂-VAS_c评分为1分,并伴急性冠脉综合征患者的不同抗栓治疗策略方案及其优劣。结果 文献提示,CHA₂DS₂-VAS_c评分为1分出血低危患者,建议尽早服用抗凝药。双联抗栓（华法林+氯吡格雷）能够有效抗栓并且降低患者出血风险,因此需根据患者的具体情况,尽快将三联调整为双联抗栓（1~3个月内）,保证患者疗效的情况下,降低患者出血风险。结论 临床上遇到相关患者需充分评估患者的出血及血栓风险,制定个体化的抗栓治疗策略。     

心房颤动合并慢性肾脏病患者口服抗凝药物治疗的研究进展

慢性肾病与心房颤动（房颤）密切相关并常常共存。慢性肾病和房颤均是血栓发生的危险因素,因此房颤合并慢性肾病人群其缺血性卒中及体循环栓塞的风险显著增加。对于普通的房颤人群,口服抗凝药物治疗是预防缺血性卒中和体循环栓塞发生的有效干预手段,并且慢性肾病还会增加出血风险,因此合并慢性肾病的房颤人群进行口服抗凝药物治疗可能并不具有临床净获益。目前针对房颤合并慢性肾病人群口服抗凝药物的疗效与安全性研究结论尚存争议,其获益风险比不明确。本文对房颤合并慢性肾病患者口服抗凝药物治疗现状作一综述,旨在为临床提供参考。     

Anticoagulation during Cardioversion in Patients with Atrial Fibrillation

The role of anticoagulation in the long-term treatment of atrial fibrillation (AF) has been well established in prospective randomized trials. Less certainty exists on the optimal anticoagulation in the setting of AF cardioversion. Current guidelines advocate anticoagulation for 3–4 weeks before and after cardioversion of AF of >48 hours’ duration. Alternatively, early cardioversion may be performed after exclusion of left atrial thrombi by transesophageal echocardiography. However, with conventional anticoagulation, the risk of bleeding has to be considered and, thus, anticoagulation is frequently underused in the clinical setting. Moreover, the role of cardioversion has been questioned by recent trials suggesting no benefit of sinus rhythm restoration over rate control in AF. This article aims to summarize the currently available data on anticoagulation in cardioversion of AF in the context of these new studies and points to some new drugs such as low-molecular weight heparins and oral thrombin inhibitors that may lead to safer anticoagulation for prevention of thromboembolic complications of AF in the future.     

Review of Challenges in Optimizing Oral Anticoagulation Therapy for Stroke Prevention in Atrial Fibrillation

Oral anticoagulant therapy is the mainstay of stroke prevention in patients with atrial fibrillation; it is highly effective at reducing stroke risk, but its use can be limited by increased risk of bleeding. As new oral anticoagulants are available, barriers to optimal use of oral anticoagulation therapy warrant consideration by healthcare professionals and administrators who are seeking to optimize the quality of care for patients with atrial fibrillation. Suboptimal use of oral anticoagulation therapy constitutes an important health problem with significant humanistic and economic consequences. Based on a review of the medical literature published between 2000 and 2011, this article summarizes the literature on the barriers to optimal use of oral anticoagulation therapy, describes the clinical and economic burdens that these barriers add to the burden of atrial fibrillation, and discusses how well the new oral anticoagulants may address some of these issues.     

房颤患者规范化抗凝治疗现状调研

目的:了解心房颤动患者规范化抗凝治疗现状,分析影响规范化抗凝治疗的因素,同时为进一步提出相应的对策打下基础。方法:查阅2010年1～12月份南京鼓楼医院心内科明确诊断患有非瓣膜性心房颤动的患者病历,采用CHADS2风险评分法对这些患者进行出血风险评估,根据ACC/AHA/ESC心房颤动治疗指南评价其规范化抗凝情况。结果:共入选患者200名,使用华法林进行抗凝治疗的仅39人(19.5%),其中仅有18人(46%)国际标准化比值(INR)达目标抗凝范围(INR:2.0～3.0);按照CHADS2评分将入组患者分组,其中高危患者143人中,进行华法林抗凝治疗的仅31人。结论:心房颤动患者进行规范抗凝治疗的比例很低(40%),其中高危患者中使用华法林进行规范治疗的比例尤甚(22%)。由此,应针对房颤患者规范化抗凝治疗率低的现状,进一步调查与了解发生这一现象的原因,从而采取有效的干预措施,提高房颤患者规范化抗凝治疗率。     

心房颤动患者导管射频消融术后利伐沙班抗凝治疗的回顾分析

摘 要 目的：评价利伐沙班用于心房颤动患者导管射频消融术（RFCA）术后3个月抗凝治疗的有效性及安全性。 方法: 采用回顾性分析方法,收集2014年1月～2015年10月我院房颤RFCA患者141例,按治疗用药不同分为利伐沙班组70例和华法林组71例。利伐沙班组RFCA术后给予利伐沙班10 mg,po,qd,至少应用3个月;华法林组RFCA术前给予低分子肝素100 IU·kg^-1,ih,术后口服华法林3～5 mg,po,qd,与低分子肝素桥接治疗,调整剂量维持国际标准化比值（INR）在2.0～3.0之间,至少应用3个月。观察两组总死亡率、血栓栓塞事件发生率和出血发生率。结果: 两组总死亡率、脑卒中率（短暂性脑缺血,缺血性脑病）、外周血管栓塞率比较,差异均无统计学意义（P＞0.05）;两组均无大出血事件发生,少量出血及不明显出血比较,差异也无统计学意义（P＞0.05）。上述少量出血患者停用药物后无再出血发生,不明显出血患者经药物剂量调整后均未进一步出血。结论:口服利伐沙班用于血栓栓塞低、中危非瓣膜房颤患者RFCA术后抗凝治疗安全、有效。     

房颤合并肝硬化患者的口服抗凝药物选择及抗栓策略研究

目的 探讨房颤合并肝硬化患者临床治疗中口服抗凝药物的选择及安全性。方法 在1例房颤合并乙型肝炎肝硬化患者房间隔修补术后抗栓方案的制定中,通过查阅指南和文献,总结、分析房颤合并肝硬化患者口服抗凝药物的疗效及安全性评价现状。结果 通过综合评估患者情况,停用华法林,予达比加群酯110 mg,bid,联合氯吡格雷75 mg,qd抗栓6个月,之后达比加群酯110 mg,bid长期抗凝治疗。结论 房颤合并肝硬化患者抗栓治疗,应充分评估血栓及出血风险,制定个体化的抗栓策略。房颤合并Child-Pugh A级肝硬化,新型口服抗凝药均可使用;合并Child-Pugh C级肝硬化,口服抗凝剂均不建议使用;合并Child-Pugh B级肝硬化,出血风险高的患者长期抗凝治疗中可选用小剂量达比加群酯。     

Thrombocytopenia Associated with Antithrombotic Therapy in Patients with Cardiovascular Diseases

Agents with antiplatelet and anticoagulant activity have been proved to be effective in reducing the incidence of complications following acute coronary syndrome, percutaneous coronary intervention, and cardiopulmonary bypass. However, these agents, including heparin, glycoprotein IIb/IIIa receptor inhibitors, and thienopyridines, are associated with increased risk of bleeding and thrombocytopenia and have been administered together with increasing frequency in a variety of cardiovascular settings. Therefore, clinicians must be familiar with the safety and rational use of these potent antithrombotic agents. Clinical features of thrombocytopenia range from bleeding to thrombosis, even death, and therapy is very different depending on the underlying cause. Additionally, patients may sometimes need urgent intervention or surgery. Thus, it is essential to quickly discriminate the etiology and start appropriate therapy. This review highlights the pathogenesis, clinical and laboratory manifestation, differential diagnosis, and treatment of antithrombotic drug-induced thrombocytopenia in cardiovascular diseases.     

房颤患者左心耳结构功能的改变与左心耳血栓形成的关系探讨

探讨心房颤动（房颤）患者左心耳的形态结构,左心耳的功能改变与左心耳血栓形成的关系及临床意义。采用经食管三维超声心动图检测114例房颤组患者及54例对照组的左心耳开口面积（LAA-O）、左心耳长径（LAA-L）、左心房容积（LA-V）、左心耳容积（LAA-V）、左心耳血流速度(LAA-v)及左心耳射血分数（LAA-EF）。进一步将房颤组分为无自发显影组（NSEC组）、自发显影组（SEC组）及血栓组（TH组）3个亚组。并将各指标与对照组进行比较,同时观察房颤各亚组之间指标变化,并进行统计学分析。房颤患者的左心耳开口面积、左心耳长径、左心房容积、左心耳容积均高于非房颤患者。房颤患者的左心耳血流速度、左心耳射血分数低于非房颤患者。房颤组组内各观察指标有以下变化：TH组左心耳容积、左心耳开口面积及左心房容积大于NSEC组（P＜0.05);3组间左心耳长径、左心耳射血分数有显著性差异（P＜0.05）;TH组及SEC组左心耳血流速度明显小于NSEC组（P＜0.05）。房颤患者左心耳内血栓形成与左心耳的结构以及功能改变密切相关。     

我院心房颤动合并慢性肾脏病患者抗凝治疗状况的分析

目的：回顾性分析我院心房颤动（房颤）合并慢性肾脏病（CKD）患者的抗凝治疗状况,为提高抗凝治疗的合理性、安全性提供参考。方法：随机收集南通市第一人民医院2014年1月～2015年12月房颤合并CKD患者90例以及房颤但肾功能正常者90例的病历资料。对患者华法林使用率、抗血小板药使用率、抗栓药物的出血不良反应等情况进行分析,并分析年龄、合并慢性疾病、既往脑血管事件、出血风险评分等单因素对华法林使用率的影响。结果：房颤合并CKD患者的抗栓比例为68.9%,其中华法林抗凝比例为10.0%,低于肾功能正常患者;合并CKD患者的抗栓药物出血不良反应发生率为6.45%, CKD并未增加抗栓药物的出血不良反应发生率。华法林使用单因素分析提示高龄、冠心病、CKD对其影响较大。结论：我院房颤合并CKD患者的抗凝治疗严重不足。临床药师应加强药学服务,协助医师制定个体化用药方案,开展药学跟踪随访工作,确保抗凝治疗的延续性以及安全性。