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我国在非瓣膜性心房颤动(NVAF)患者的卒中和短暂性脑缺血发作(TIA)预防正面临巨大挑战,合理使用华法林能显著降低心房颤动患者发生首发卒中或TIA的风险。但是,在临床实践中,心房颤动患者的华法林使用却存在不足。《中国非瓣     

真实世界非瓣膜性房颤患者口服抗凝药物的使用研究

目的：探索专门的抗凝门诊非瓣膜性房颤(Non-valvular atrial fibrillation,NVAF)患者口服抗凝药物的使用情况,为真实世界临床实践提供指导。方法：对于2014年至2018年抗凝门诊接受口服抗凝药物(Oral anticoagulants,OAC)治疗的NVAF患者的情况进行回顾性分析。结果：选择服用华法林者551人,达比加群酯者83人,利伐沙班者48人;服用3药物的NVAF患者中CHA2DS2-VASc评分男性≥1分、女性≥2分者分别占89.7%、94.0%和93.8%;卒中低危患者中约50%为复律或射频消融前3周或后4周抗凝治疗;使用NOACs患者的平均年龄和既往有卒中史的比例高于华法林的患者。由于NOACs使用的方便性,临床实践中华法林转换为NOACs最为常见;仍有相当多的抗凝药物不依从的情况,其中1例患者因自行停用达比加群酯3天导致短暂性脑缺血发作。结论：与目前临床指南的推荐不同,真实世界使用华法林者占绝大多数,NOACs较多用于高龄或既往卒中的患者,不同抗凝药物之间转换的监护以及改善服药的依从性是提高抗凝质量的重要举措。     

利伐沙班与华法林在非瓣膜性房颤患者抗凝治疗中的疗效与安全性对比

目的 对比利伐沙班与华法林在非瓣膜性心房颤动(非瓣膜性房颤,NVAF)患者抗凝治疗中的疗效与安全性.方法 139例NVAF患者,随机分为实验组(76例)和对照组(63例).实验组使用利伐沙班进行抗凝治疗,对照组使用华法林进行抗凝治疗.比较两组患者的用药依从性、有效性与安全性.结果 实验组患者完成实验占比略低于对照组,但...     

新型抗凝药物在心脑血管疾病中的临床评价

心房颤动是缺血性脑卒中的重要独立危险因素,抗凝治疗是预防非瓣膜性心房颤动(NVAF)患者缺血性卒中的有效方法。传统抗凝药物华法林疗效肯定但使用不便。直接凝血酶抑制剂及Ⅹa因子抑制剂干扰凝血过程,抗凝作用肯定,具有剂量固定、无需监测凝血指标的优点,受到临床重视。本文对此类新型抗凝药物的药理作用、药代动力学及临床评价等做一综述。     

华法林预防老年性心房纤颤患者 缺血性脑卒中的临床观察

［摘要］目的探讨华法林对于老年非瓣膜病性心房颤动（NVAF）患者抗凝治疗的有效性和安全性。方法96例老年NVAF患者随机分为两组各48例：治疗组每日服华法林1次，调节其剂量使国际标准化比值（INR）维持在2.0～3.0。对照组每日口服阿司匹林150 mg。观察两组缺血性脑卒中及出血等不良反应的发生情况。结果治疗组栓塞发生率为2.08%，对照组16.67%(P＜0.05)，两组出血不良反应比较差异无显著性(P＞0.05)。结论预防老年NVAF患者缺血性脑卒中的发生，华法林比阿司匹林具有更显著的效果，且安全性好。     

AECOPD患者抗凝药物应用调研与合理性评价

摘要：目的:探讨慢性阻塞性肺病急性加重期(AECOPD)患者抗凝药物的临床应用情况,并评价其应用合理性。方法:采用回顾性分析方法,收集2019年1～12月在我院接受抗凝治疗的AECOPD患者资料,包括性别、年龄、合并症、抗凝药物使用情况、凝血指标及不良反应信息等,评估患者肺栓塞和非瓣膜性心房颤动(NVAF)的危险因素,评价抗凝效果与抗凝药物使用合理性。结果:AECOPD患者预防用抗凝药物7～14 d后凝血功能指标较治疗前有明显改善(PSymbol|@@0.05);AECOPD伴静脉血栓栓塞症(VTE)发生率为21.35%,患者采用华法林治疗出院时INR达标率<50%,出院后继续抗凝比例<50%; AECOPD伴NVAF发生率为30.19%,患者出院后抗凝比例约61.39%。华法林是我院治疗AECOPD伴VTE或NVAF的首选药物,新型口服抗凝药物选择较少;抗凝药物致出血不良反应共6例。结论:我院AECOPD患者VTE及NVAF发生率高,临床治疗药物选择符合指南要求,华法林仍占主导地位,新型口服抗凝药(NOACs)选择相对较少,VTE及NVAF抗凝治疗存在明显不足,需引起临床高度重视。     

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。     

华法林抗凝治疗强度对老年稳定性冠心病合并非瓣膜性心房颤动患者的疗效及预后的影响分析

目的 探讨华法林抗凝治疗强度对老年稳定性冠心病合并非瓣膜性心房颤动患者的疗效及预后的影响.方法 选取本院2012年2月至2014年3月收治的96例老年稳定性冠心病合并非瓣膜性心房颤动患者进行研究,按随机数字表法将其分为研究组(低强度华法林抗凝治疗)和对照组(中强度华法林抗凝治疗),治疗后平均随访2年,比较两组患者药物服用情况、主要终点、次要终点及安全性.结果 研究组INR与华法林用量均低于对照组,差异有统计学意义(均P＜0.05).其余药物服用情况组间比较差异无统计学意义(均P＞ 0.05).两组患者缺血性脑卒中及体循环栓塞发生率组间比较,差异无统计学意义(均P＞ 0.05).两组患者全因死亡联合终点及非致命性心肌梗死发生率组间比较,差异无统计学意义(均P＞ 0.05).研究组轻度出血及总出血事件发生率低于对照组,差异有统计学意义(均P＜0.05).严重出血事件发生率组间比较,差异无统计学意义(P＞0.05).结论 低强度及中强度华法林抗凝治疗在老年稳定性冠心病合并非瓣膜性心房颤动患者中疗效相近,但低强度华法林抗凝治疗安全性更佳.     

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。     

观察ROC曲线用于评估非瓣膜心房颤动患者华法林抗凝出血风险

目的 观察非瓣膜心房颤动(NVAF)患者华法林抗凝出血风险.方法 回顾性分析2008年1月至2012年6月我科收治的口服华法林抗凝治疗NVAF患者177例,其中抗凝治疗过程中发生出血事件者56例(出血组);未出现出血事件者121(非出血组).比较2组患者华法林用量、国际标准化比值(INR)有无差别.结果 2组患者华法林用量差别无统计学意义(P=0.40);出血组INR显著高于非出血组(P＜0.01);2组患者INR与华法林用量间不存在明显相关性(P =0.062);INR判断出血风险的敏感性为75.4％,特异性为80.2％.结论 INR可作为评估出血风险的重要指标,随INR增大患者出血风险明显增加.     

Adequacy of anticoagulation in patients with atrial fibrillation coming to a hospital

STUDY OBJECTIVE: To evaluate the adequacy of anticoagulation in patients with atrial fibrillation (AF) coming to a hospital. DESIGN: Retrospective medical record review. SETTING: Tertiary care hospital. PATIENTS: Consecutive patients with a history of AF who had been prescribed warfarin and who had the international normalized ratio (INR) measured when they arrived at the hospital. Those who developed AF as a complication during hospitalization were excluded. MEASUREMENTS AND MAIN RESULTS: Of 1085 patients, 375 (mean age 73 yrs, 56.3% men) were eligible for further evaluation. Most had nonvalvular AF; in 44.5% the INR was subtherapeutic, in 36.5% it was therapeutic, and in 18.9% it was supratherapeutic. Patients admitted for any thromboembolic event and for ischemic stroke were significantly more likely to have subtherapeutic INRs. CONCLUSION: It is well documented in the literature that warfarin is underprescribed, but our results suggest that even in treated patients, about half are inadequately protected from thromboembolism.     

Impact of renal function on ischemic stroke and major bleeding rates in nonvalvular atrial fibrillation patients treated with warfarin or rivaroxaban: a retrospective cohort study using real-world evidence

Objectives: Renal dysfunction is associated with increased risk of cardiovascular disease and is an independent predictor of stroke and systemic embolism. Nonvalvular atrial fibrillation (NVAF) patients with renal dysfunction may face a particularly high risk of thromboembolism and bleeding. The current retrospective cohort study was designed to assess the impact of renal function on ischemic stroke and major bleeding rates in NVAF patients in the real-world setting (outside a clinical trial).

Methods: Medical claims and Electronic Health Records were retrieved retrospectively from Optum’s Integrated Claims–Clinical de-identified dataset from May 2011 to August 2014. Patients with NVAF treated with warfarin (2468) or rivaroxaban (1290) were selected. Each treatment cohort was stratified by baseline estimated creatinine clearance (eCrCl) levels. Confounding adjustments were made using inverse probability of treatment weights (IPTWs). Incidence rates and hazard ratios of ischemic stroke and major bleeding events were calculated for both cohorts.

Results: Overall, patients treated with rivaroxaban had an ischemic stroke incidence rate of 1.9 per 100 person-years (PY) while patients treated with warfarin had a rate of 4.2 per 100 PY (HR?=?0.41 [0.21–0.80], p?=?.009). Rivaroxaban patients with an eCrCl below 50?mL/min (N?=?229) had an ischemic stroke rate of 0.8 per 100 PY, while the rate for the warfarin cohort (N?=?647) was 6.0 per 100 PY (HR?=?0.09 [0.01–0.72], p?=?.02). For the other renal function levels (i.e. eCrCl 50–80 and ≥80?mL/min) HRs indicated no statistically significant differences in ischemic stroke risks. Bleeding events did not differ significantly between cohorts stratified by renal function.

Conclusions: Ischemic stroke rates were significantly lower in the overall NVAF population for rivaroxaban vs. warfarin users, including patients with eCrCl below 50?mL/min. For all renal function groups, major bleeding risks were not statistically different between treatment groups.     

Comparing the economic burden of ischemic stroke patients with and without atrial fibrillation: a retrospective study in Beijing,China

Background: Little is known about the economic burden for ischemic stroke (IS) patients with atrial fibrillation (AF) in China.

Aim: We aimed to compare the economic burden of treatment-related costs in IS patients with AF vs. without AF in China.

Methods: This retrospective analysis used economic burden data from the Beijing urban health insurance database. Using a random sampling method, 10% of the patients diagnosed with IS from 1 January through 31 December 2012 were enrolled. First hospitalization was considered as the index event and hospital utilization after the index event was followed up until September 2013. Overall healthcare cost during the study period was analyzed.

Results: In 4061 patients with IS (mean?±?SD age, 68.45?±?13.95 years; AF: 992; without AF: 3069), the AF group had a higher percentage of patients with co-morbidities at baseline. Compared with the non-AF group, the AF group had significantly greater hospitalization at the index event (p?p?Conclusions: AF increased the use of healthcare resources, treatment cost, and economic burden in patients with IS. Therefore, prevention of cardio-embolic events in patients with AF by anticoagulants may decrease the economic burden in patients with IS.     

Secondary prevention of stroke in patients with nonvalvular atrial fibrillation: optimal intensity of anticoagulation

Nonvalvular atrial fibrillation (NVAF) is frequently seen in elderly people and has become a main cause of cardioembolic stroke. The efficacy of anticoagulation for primary prevention of stroke or transient ischaemic attacks (TIAs) in patients with NVAF has been established by prospective, randomised and controlled trials. Warfarin decreased the frequency of all strokes by 68% and the rate of the combined outcome of stroke, systemic embolism or death by 48%. Anticoagulation with warfarin using international normalised ratios (INRs) ranging from 2.0 to 3.0 is recommended for patients with NVAF, who have any of the risk factors identified by the Atrial Fibrillation Investigators (AFI) [previous stroke or TIA, history of hypertension, diabetes mellitus, advanced age (> or = 65 years old), congestive heart failure and coronary artery disease], the American College of Chest Physicians (ACCP) [increased age (> 75 years old), prior stroke, hypertension and heart failure], or the Stroke Prevention in Atrial Fibrillation (SPAF) investigators [women > 75 years old, prior stroke, systolic blood pressure > 160mm Hg, recent heart failure, and fractional shortening < 25% on echocardiography]. For the secondary prevention of stroke, the efficacy of adjusted-dose warfarin therapy has been demonstrated by 2 major randomised trials. SPAF III (INR 2.0 to 3.0) demonstrated a lower incidence of ischaemic stroke or systemic embolism (3.4 %/year) compared with low fixed-dose warfarin plus aspirin (acetylsalicylic acid) [11.9%]. The European Atrial Fibrillation Trial [EAFT] (INR 2.5 to 4.0) showed a lower incidence of all stroke (4.0 %/year) with adjusted-dose warfarin compared with placebo (12.0 %/year). The incidence of major bleeding in the adjusted-dose warfarin group in SPAF III and EAFT was 2.4 and 2.8 %/year, respectively. EAFT incidence rates for the occurrence of a first ischaemic or haemorrhagic complication analysed by INR range indicated that the rate was lowest at INRs of 2.0 to 2.9, and higher with INRs of 3.0 to 3.9. Therefore, the optimal intensity of anticoagulation for prevention of recurrent stroke seems to be an INR of between 2.0 and 3.0, as for primary prevention. Retrospective and prospective studies from Japan reported that in the elderly, haemorrhagic complications occur frequently with INRs above 2.6 and major ischaemic events cannot be prevented at INRs below 1.6. Therefore, an INR target between 1.6 and 2.6 may be an alternative for secondary prevention of stroke in elderly patients with NVAF who have a potential risk of bleeding, to avoid both major ischaemic and haemorrhagic events. Antiplatelets may be administered in patients who are unable to manage taking warfarin properly or who have a high risk of falling and subsequently sustaining a head injury, although the efficacy of antiplatelets for secondary prevention of stroke in NVAF has not yet been established.     

New evidences for old concerns with oral anticoagulation in atrial fibrillation: focus on dabigatran

Introduction: Nonvalvular atrial fibrillation (NVAF) is associated with a fivefold excess risk of stroke. Antithrombotic therapy is crucial to reduce the risk of stroke. During past decades, vitamin K antagonists (warfarin or acenocoumarol) have been widely used for this purpose. However, they have several disadvantages that limit their daily use in clinical practice.

Areas covered: In patients with NVAF at risk of stroke, the randomized evaluation of long-term anticoagulation therapy (RE-LY) trial demonstrated that, compared with warfarin, dabigatran 150 mg b.i.d. was associated with lower rates of stroke and systemic embolism but similar rates of major hemorrhage, whereas dabigatran 110 mg b.i.d. exhibited similar rates of stroke and systemic embolism, but lower rates of major hemorrhage. Fortunately, data about dabigatran are not limited to RE-LY trial. In fact, many substudies have been drawn, providing new and important evidences about the benefits of dabigatran.

Expert opinion: The most recent evidences about efficacy and safety of dabigatran in patients with NVAF, focusing on different substudies of RE-LY trial, are reviewed. In summary, dabigatran is beneficial not only in general population with NVAF but also in different subgroups of patients or different clinical settings (i.e., CHADS2 score, INR control, type of AF, elderly, previous transient ischemic attack or stroke, cardioversion and so on).     

The hidden costs of anticoagulation in hospitalized patients with non-valvular atrial fibrillation

Introduction: Non-valvular atrial fibrillation (NVAF) and ischemic stroke are collectively associated with annual hospital costs of tens of billions of dollars in the USA. Oral anticoagulant (OAC) treatment with warfarin reduces the risk of stroke in patients with NVAF. Unfortunately, because of the complexity of warfarin therapy and potential for adverse events (AEs), many patients who might benefit go untreated or receive suboptimal therapy, increasing their stroke and/or bleeding risk.

Areas covered: This review explores current hospital costs and resource utilization for NVAF patients on warfarin therapy and the potential impact of newer OACs in this area.

Expert opinion: Many ischemic strokes could be prevented through wider use of OACs. Further, admissions due to anticoagulant-associated AEs could be reduced by optimizing OAC therapy. In the hospital, specialized anticoagulation services can decrease costs by improving the effectiveness of warfarin management, empowering patients through education and optimizing care transitions. With fewer interactions and no dose titration or monitoring required, the novel OACs (NOACs) have the potential to further decrease inpatient resource utilization and costs. It is important that, as data become available, inpatient costs are included in cost–benefit comparisons between warfarin and the NOACs.     

Anticoagulant Use, the Prevalence of Bridging, and Relation to Length of Stay among Hospitalized Patients with Non-Valvular Atrial Fibrillation

Objective: The objectives of this study were to describe inpatient anticoagulation and bridging in patients with non-valvular atrial fibrillation (NVAF) and to identify whether differences exist in length of stay (LOS) among bridged versus non-bridged NVAF patients. Design: Administrative claims data were used to select patients ≥18 years with a primary or secondary discharge diagnosis of NVAF and inpatient warfarin use from 1 July 2004 to 30 September 2009. Patients with valvular or transient causes of NVAF or pregnancy were excluded. Inpatient bridging was defined as receipt of an anticoagulant in addition to warfarin during the hospitalization. LOS was reported for non-bridged patients (warfarin only) and compared with three bridging regimens: low molecular weight heparin/pentasaccharide (LMWH/PS); unfractionated heparin (UFH); and two-agent bridging (LMWH/PS and UFH). Multivariate analyses were performed to evaluate the association between bridging and LOS, adjusting for demographic and clinical variables. Results: Of 6340 NVAF patients, 48% received inpatient warfarin (mean LOS 5.5 days); among them, 64% received bridging therapy (mean LOS 6.3 days) [LMWH/PS 45% (mean LOS 5.6 days), UFH 36% (mean LOS 6.0 days), two-agent bridging 18% (mean LOS 8.4 days)]. Following multivariate analysis, relative to patients who received inpatient warfarin only, LOS was significantly higher for patients with UFH (19.3%) and patients with two-agent bridging (45.1%). Patients with pre-period warfarin, cancer, or diabetes mellitus who received bridging agents had significantly longer LOS than patients with those conditions who were not bridged. Conclusion: LOS was longer for bridged than non-bridged patients. Further studies are needed to identify predictors of bridging and to explain why bridged NVAF patients had longer LOS.