非瓣膜病性心房纤颤及其合并脑栓塞患者的抗凝治疗

目的探讨非瓣膜病性心房纤颤(房颤)及其合并脑栓塞患者的抗凝治疗情况。方法采集2012年1月~2013年12月于苏州大学附属第二医院治疗的208例心源性脑栓塞患者的临床资料,对其中存活的164例非瓣膜病性房颤(包括华法林抗凝治疗34例,抗血小板治疗130例)以及另行采集的36例一级预防华法林抗凝治疗的非瓣膜病性房颤患者随访1年。分析70例华法林抗凝治疗患者的基本情况,并依据预防等级、年龄、国际标准化比值(INR)控制水平、1年内是否继发出血进行分组比较,并分析与稳态时华法林剂量相关的因素。结果 164例非瓣膜病性房颤合并脑栓塞患者中,华法林抗凝组患者年龄、入院NIHSS评分明显低于抗血小板组,INR、1年内颅内外出血发生率明显高于抗血小板组(均P0.05)。70例抗凝治疗患者中,与二级预防相比,一级预防的患者年龄、房颤患者口服抗凝药物出血评分(HAS-BLED评分)和1年停用华法林的比例明显降低,身高、体质量和华法林初始剂量明显增高(均P0.05);与65岁的患者相比,≥65岁患者的房颤患者脑卒中风险评分和HAS-BLED评分明显增高,华法林初始剂量和稳态华法林剂量明显降低(均P0.05);INR 1.5~2.0的与INR 2.1~3.0的患者临床资料比较,差异均无统计学意义(均P0.05);与1年内未继发出血的患者比较,1年内继发出血的患者入院NIHSS评分明显增高,初始INR水平明显降低(均P0.05)。稳态时华法林剂量与年龄呈负相关,与初始华法林剂量呈正相关(均P0.05)。结论对于非瓣膜病性房颤合并脑栓塞患者而言,华法林抗凝治疗较抗血小板治疗的出血风险高。对于华法林抗凝治疗的非瓣膜病性房颤患者而言,一级预防较二级预防的患者年龄更轻、服药依从性好;低抗凝强度(INR 1.5~2.0)与传统抗凝强度(INR 2.1~3.0)在降低脑卒中发生率、出血风险方面无明显差别;年龄较轻患者华法林初始剂量及稳态时剂量均较高,但脑卒中风险及出血风险较低。     

新型口服抗凝药预防非瓣膜性房颤发生脑卒中的研究进展

缺血性脑卒中是房颤最严重的并发症,国内外指南均推荐非瓣膜性房颤患者口服抗凝药来预防脑卒中的发生。华法林是预防非瓣膜性房颤患者脑卒中最有效的药物,但因其的众多缺点限制了广泛应用。目前很多临床试验表明新型口服抗凝药物(达比加群酯、利伐沙班、阿哌沙班等)克服了华法林的缺点,并有很好的预防效果。但是因为其增加了房颤患者胃肠出血风险、需要根据肾功能调整药量、无有效的拮抗剂、价格昂贵等原因并未广泛应用于临床。     

缺血性脑卒中患者中无症状心房颤动的临床意义

心房颤动(房颤)是临床上最常见的心律失常,左房内(主要是左心耳)内血栓形成脱落可导致缺血性脑卒中.已经发生了缺血性脑卒中的房颤患者1年内卒中复发率明显增高[1～3],华法林抗凝治疗能显著降低复发率[1,3,4].     

老年心房纤颤患者口服华法林预防脑卒中疗效观察

目的探讨老年心房纤颤患者适合的抗凝治疗防治脑卒中的发生。方法选择老年心房纤颤患者分为华法林组(100例)和阿司匹林组(50例),2组病因、病程、年龄、性别均有可比性,分别口服华法林、阿司匹林,观察其有效性和安全性。结果华法林组在预防老年心房纤颤继发脑卒中的疗效明显高于阿司匹林组,华法林组治疗期间发生颅内出血的风险略低于阿司匹林组。结论老年心房纤颤患者口服华法林是预防脑卒中的重要的、安全的手段之一。     

老年非瓣膜病性心房纤颤并发缺血性脑卒中52例临床分析

非瓣膜病性心房颤动(房颤)是老年人最常见心律失常之一,是并发脑卒中的重要病因,具有较高的病死率和致残率。根据2004年在我国14个省市29 079例自然人群进行的一项调查显示,我国房颤的患病率约0.77%,50~59岁中约为0.5%,>80岁的人群高达7.5%。由于抗凝药物华法林需要长期监测凝血功能,且易出血,安全剂量窗口低,所以患者对预防性抗凝治疗用药的依从性差,致使房颤并发脑卒     

低强度抗凝联合双重抗血小板治疗对心房颤动患者冠脉支架术后脑卒中的预防效果

目的观察心房颤动患者冠脉支架术后低强度抗凝联合双重抗血小板治疗预防脑卒中的作用。方法选取164例因稳定性冠心病或急性冠脉综合征接受冠脉支架术的持续性或永久性房颤患者,分为低强度抗凝治疗组(LIA组,n=86,华法林剂量滴定至INR1.5~2.0)和常规抗凝治疗组(CIA组,n=78,华法林剂量滴定至INR 2.0~3.0),同时接受双重抗血小板治疗(阿司匹林100mg/d+氯吡格雷75mg/d),随访1a后比较组间脑卒中/短暂性脑缺血发作(TIA)或外周栓塞事件、出血事件和主要不良心脏事件(MACE)发生率。结果与CIA组相比,LIA组脑卒中/TIA或周围动脉栓塞事件和主要心脏不良事件发生率差异无统计学意义(P0.05),出血事件发生率明显降低(LIA组9.3%vs.CIA组15.4%,P0.05)。结论低抗凝强度华法林联合双重抗血小板治疗是房颤患者冠脉支架术后预防脑卒中安全有效的预防措施。     

家庭自测国际标准化比值对抗凝临床事件的影响

背景:华法林抗凝治疗可减低房颤患者或人工心脏瓣膜患者的血栓栓塞并发症,但高质量门诊抗凝检测的有效管理较为复杂,国际标准化比值(INR)常常超出目标范围,而且需要患者集中到门诊接受检测,限制了检测频度,一些患者因此不能接受口服抗凝治疗.     

达比加群酯预防心房颤动患者发生脑梗死的临床疗效及安全性分析

目的探讨达比加群酯在预防非瓣膜性心房颤动(房颤)患者发生脑梗死的临床疗效及安全性。方法选取2014-01—2016-01在我院住院治疗的心房纤颤患者120例为研究对象,将所有患者随机分为对照组与试验组,每组60例,对照组口服华法林治疗,试验组口服达比加群酯治疗,对比2组3个月内的脑栓塞或血栓形成事件发生率、出血事件的发生率。结果 3个月内2组均未出现大出血、出血性脑卒中及死亡事件。达比加群酯与华法林对预防非瓣膜房颤患者脑卒中、栓塞或血栓形成事件的发生率相似,而出血发生率小于华法林(P0.05)。结论达比加群酯在预防脑卒中事件上与华法林相似,并不增加出血风险;且具有安全性好、使用简单、不需要频繁监测INR值等优点。     

华法林防治非瓣膜性房颤并发脑栓塞疗效观察

非瓣膜性房颤是临床常见的快速型房性心律失常[1],而房颤最常见的并发症是脑栓塞及周围动脉栓塞,占所有脑卒中原因的15%～20%,是正常窦性心律发生脑栓塞5倍,且神经功能严重障碍和病死率高于正常窦性心律患者.在对非瓣膜性房颤进行房颤抗栓治疗中华法林与肠溶阿司匹林均是常用的抗凝治疗药物,但华法林应用率较低,我们比较2种药物预防脑栓塞的疗效,现报道如下.     

心房颤动危险分层后固定剂量低强度华法令抗凝治疗的1年随访

心房颤动(房颤)是临床上最常见的心律失常之一,随着年龄的增加发病率逐步升高,高达15％的脑卒中患者曾患有慢性房颤;随机临床试验证实剂量调整的华法令抗凝治疗能使脑卒中的发生率降低64％[1],然而,并非所有的房颤患者都需要抗凝治疗,为此提出了房颤患者脑卒中危险分层的策略[2],即使用CHADS2评分筛选出脑卒中高危的患者接受抗凝治疗,这种分层方法能否适合中国人群还未得到广泛证实.     

Antithrombotic and anticoagulation therapy after stroke and transient ischemic attacks

Patients with a transient ischemic attack (TIA) or ischemic stroke are at high risk for a recurrent stroke. Platelet inhibitors can reduce this risk in patients with non-cardioembolic stroke or TIA. Aspirin is used for secondary prevention in patients with a low risk of recurrent stroke while the combination of aspirin and dipyridamole or clopidogrel is recommended in patients with a higher risk. Patients with atrial fibrillation have a five-fold increased risk of stroke. In comparison to placebo oral anticoagulation reduces the risk of stroke by 60-70% in primary and secondary stroke prevention. Aspirin can still reduce the relative stroke risk by 22% in patients with atrial fibrillation who have contraindications against anticoagulation. Given the limitations of oral anticoagulation with vitamin K antagonists a new generation of anticoagulants is currently being investigated which include factor Xa inhibitors and direct thrombin antagonists. Dabigatran has been shown to be as efficacious as warfarin given at a lower dose and significantly more efficacious when administered at a higher dosage. Both cerebral and intracranial hemorrhages were reduced by 60-80% in patients treated with dabigatran when compared to warfarin.     

Atrial fibrillation and stroke management: present and future

Stroke remains the leading cause of disability and the third leading cause of death. Despite advances in treatment, the early and later outcomes remain poor with a high rate of death and or disability. Strategies for prevention have assumed a central role. Given the close relationship between advancing age, atrial fibrillation, and increasing stroke, there is great interest in this large specific population of patients. Although warfarin has been the cornerstone of therapy for stroke prevention in patients with atrial fibrillation, it is often not used because of absolute or relative contraindications, or is ineffective because of poor control of the international normalized ratio (INR). The relative risk-benefit ratio of stroke prevention versus bleeding hazard plays a central role in therapeutic decisions. New pharmacologic approaches have been studied, most recently direct thrombin inhibitors. These drugs may be associated with less bleeding than warfarin, although there continues to be incremental bleeding risk over a patient's lifetime. In patients with nonvalvular atrial fibrillation, device strategies are being tested. These are based upon the information that in such patients, stroke arises from thrombus in the left atrial appendage in 90% of cases. Left atrial appendage occlusion has now been tested in a randomized clinical trial. In this trial, device closure was found to be noninferior to warfarin for prevention of all-cause stroke, cardiac death, and systemic embolization. There was an early safety hazard typically related to periprocedural pericardial effusions; however, subsequent experience has continued to document excellent efficacy and improved safety profiles. New randomized trials and registries continue to explore the potential for device placement as an alternative to anticoagulant therapy for stroke prevention in this group of patients.     

Atrial fibrillation and stroke prevention

There is overwhelming evidence from randomized trials and systematic reviews to indicate the benefit of thromboprophylaxis in patients with atrial fibrillation. In moderate- to high-risk subjects, oral anticoagulation with warfarin reduces stroke by two-thirds, while aspirin reduces stroke by 22%. The latter result is similar to that seen for stroke reduction with antiplatelet therapy in vascular disease. Numerous studies have shown that less than half the patients eligible for warfarin therapy actually receive it and under- or overanticoagulation is common. This leads to many missed opportunities in optimizing stroke prevention in atrial fibrillation. The limitations of existing oral anticoagulants have resulted in the development of many new drugs. The aim of this review is to provide a brief overview of thromboprophylaxis in atrial fibrillation, and the opportunities for improvement in the provision made for thromboprophylaxis.     

Prevention of Stroke in Patients with High-Risk Atrial Fibrillation

Atrial fibrillation (AF) causes nearly 10% of all ischemic strokes. Long-term oral anticoagulation with warfarin currently is the best treatment for preventing stroke in patients with AF and other stroke risk factors. However, many eligible patients do not receive warfarin, and some patients with AF are unsuitable for this treatment. Recent clinical trials have tested alternatives to long-term warfarin, and some new treatment options have emerged. Nonpharmacologic approaches to stroke prevention in atrial fibrillation also are under development. In addition, new diagnostic modalities may detect paroxysmal AF with more sensitivity, potentially expanding the population to be treated and the potential impact of stroke preventive strategies on the population. This review provides a practical guide to current treatment and diagnostic options.     

Interventional treatments for stroke prevention in atrial fibrillation with emphasis upon the WATCHMAN device

PURPOSE OF REVIEW: Stroke is a leading cause of death and disability worldwide. Many strokes occur in patients with atrial fibrillation. Current guidelines recommend an antithrombotic regimen with warfarin to prevent thromboembolism in atrial fibrillation; however, a substantial number of patients are not eligible for this therapy. The exclusion of the left atrial appendage from circulation seems to be an alternative strategy for stroke prevention in atrial fibrillation. The review focuses on the different devices for stroke prevention in patients with atrial fibrillation. RECENT FINDINGS: Recently, two devices developed for percutaneous transcatheter occlusion of the left atrial appendage have been studied: the PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) device and the WATCHMAN device. Safety and feasibility data are available for both devices. About 200 patients have received a PLAATO device. These patients were at high risk for thrombembolic stroke and were not candidates for oral anticoagulation therapy. The WATCHMAN device was implanted in 75 patients that were eligible for long-term anticoagulation therapy with a moderate risk for thrombembolic stroke due to nonvalvular atrial fibrillation. SUMMARY: For both devices, a reduction in the risk of stroke was documented, and device implantation was shown to be safe and feasible. Provided the ongoing trials show noninferiority to oral anticoagulation, another therapeutic option will become available to prevent ischemic strokes.     

Atrial fibrillation and stroke prevention: is warfarin still an option? Yes

With the advent of new oral anticoagulants, the place of warfarin for stroke prevention in patients with atrial fibrillation needs re-evaluation. Warfarin is difficult to use, because of large individual differences in response and metabolism, many significant interactions with drugs and foods, and fluctuations in vitamin K absorption. It requires frequent blood testing and dose adjustments, so with good reason patients and physicians are eager for the newer agents that are easier to use. However, the purchase price of the new anticoagulants is so high that warfarin will remain in widespread use. It is important therefore for physicians to know how to use it well. Anticoagulants work much better for stroke prevention in atrial fibrillation than do antiplatelet agents; physicians need to understand the concept of red thrombus (for which anticoagulants are required) versus white thrombus—platelet aggregates—which are the target of antiplatelet agents. Stroke from atrial fibrillation increases steeply with age, and the elderly benefit disproportionately from anticoagulation. It is still necessary for physicians to know how to use warfarin, and to use it better than it has been used in the past.     

Selection of Oral Anticoagulants in Ischemic Stroke Patients with Nonvalvular Atrial Fibrillation

Background

Anticoagulant therapy is indicated for management of ischemic stroke patients with nonvalvular atrial fibrillation. We retrospectively investigated how oral anticoagulants were selected for ischemic stroke patients with nonvalvular atrial fibrillation.

Benefits and risks of oral anticoagulation for stroke prevention in nonvalvular atrial fibrillation

Nonvalvular atrial fibrillation is the most common clinically significant cardiac arrhythmia in the United States. It increases both the risk for and the severity of strokes and is associated with substantial morbidity, mortality, decreased quality of life, and related health care costs. Guidelines recommend anticoagulation therapy for the majority of patients with atrial fibrillation. Clinical trials have established that vitamin K antagonists are effective for stroke prevention for patients with atrial fibrillation for whom anticoagulation is recommended. However, vitamin K antagonists remain underutilized for a variety of reasons, including drug, physician, and patient factors. While vitamin K antagonists considerably reduce the risk of stroke, the absolute risk reduction varies according to individual patient risk factors. Accurately assessing each patient's true risk of stroke and bleeding is essential when determining which (if any) antithrombotic strategy should be used. Several stroke risk stratification schemes exist; of these, CHADS₂ is widely employed and simple. New, more sophisticated schemes may generate more precise risk estimates and better identify those patients for whom anticoagulant therapy offers a net clinical benefit. More studies are needed to determine the utility of bleeding risk stratification systems, as well as the role of surgical and interventional alternatives to anticoagulation treatment. Several novel oral anticoagulants are in (or have completed) phase 3 clinical trials. Dabigatran etexilate, approved in the United States in October 2010 for reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, now offers the first oral alternative to warfarin for patients with atrial fibrillation.     

Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke. Canadian Task Force on Preventive Health Care

BACKGROUND: Patients with stroke commonly undergo investigations to determine the underlying cause of stroke. These investigations often include ambulatory electrocardiography to detect paroxysmal atrial fibrillation. There is conflicting evidence in the literature regarding whether routine ambulatory electrocardiography should be performed in all or selected stroke patients. This paper reviews the available evidence on (1) the yield of ambulatory electrocardiography in detecting paroxysmal atrial fibrillation in patients with stroke or transient ischemic attack and (2) the effectiveness of anticoagulation in preventing recurrent stroke in patients with paroxysmal atrial fibrillation. METHODS: A MEDLINE search for primary articles was performed, and the references were reviewed manually. In addition, citations were obtained from experts. The evidence was systematically reviewed using the evidence-based methodology of the Canadian Task Force on Preventive Health Care. RESULTS: Ambulatory electrocardiography can detect atrial fibrillation not found on initial electrocardiogram in between 1% and 5% of people with stroke. Ambulatory electrocardiography is generally safe. The risk of recurrent stroke in the setting of paroxysmal atrial fibrillation is uncertain, but appears to be similar to that seen with chronic atrial fibrillation (about 12% per year). Therapy with warfarin may reduce this risk by about two-thirds as compared to placebo. The annual risk of major bleeding with warfarin therapy is between 1% and 3% but rates for individual patients depend on various specific risk factors. INTERPRETATION: There is insufficient evidence to recommend for or against the use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in either selected or unselected patients with stroke (C Recommendation). There is fair evidence to recommend therapy with warfarin for patients with stroke and paroxysmal atrial fibrillation (B Recommendation).     

Stroke prevention in nonvalvular atrial fibrillation: a review of prospective randomized trials.

Patients with atrial fibrillation are at risk for cerebral embolism; however, the roles of chronic anticoagulation or antiplatelet therapy for stroke prevention in patients with nonvalvular atrial fibrillation have been controversial. Recently, the results of three large prospective randomized trials that examined the risks and benefits of warfarin or aspirin for stroke prophylaxis in patients with nonvalvular atrial fibrillation were reported. All three studies revealed a reduction in the stroke rate for patients treated with warfarin and a small incidence of major bleeding. One of the studies also reported a reduced stroke rate in aspirin-treated patients. The reduction of thromboembolic events associated with chronic warfarin therapy appears to outweigh the risks of significant bleeding for most patients with nonvalvular atrial fibrillation. Aspirin may offer an alternative for subgroups of patients who are at low risk for stroke or those who are not good candidates for anticoagulation.