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。     

心房颤动抗栓治疗研究进展

心房颤动是临床最常见的心律失常之一,同时具有较高血栓栓塞的风险,因此其致残率和致死率高,抗凝治疗能有效预防栓塞,是心房颤动患者的首要治疗。华法林是最经典的口服抗凝药物,其他抗血小板治疗及新型口服抗凝药物为心房颤动抗栓治疗提供了新的思路。而如何平衡抗栓治疗的风险与获益给临床医师带来了挑战,现就心房颤动抗栓治疗研究进展做一综述。     

美国新版《抗栓治疗和血栓预防指南》心房颤动和瓣膜病的更新解读

2012年美国胸科医师学院(ACCP)第9版《抗栓治疗和血栓预防指南》在心房颤动(AF)抗栓治疗中强调基于CHADS2评分的危险分层抗栓策略,CHADS2评分≥1分患者均应给予口服抗凝药物,包括华法林(国际标准化比值目标2.0～3.0)和新型口服抗凝药物达比加群。不推荐应用抗血小板治疗。此外,还对特殊情况如合并冠心病以及复律时的抗凝治疗给予建议。多数风湿性瓣膜病和机械瓣膜置换术后需要口服华法林。发生感染性心内膜炎的患者不建议抗凝治疗,如患者长期抗凝也要暂时停用直至病情稳定。机械瓣膜置换术后长期华法林抗凝,人工瓣膜血栓的处理策略需要根据血栓大小和位置来决定溶栓还是外科手术治疗。     

抗栓疗法对≥80岁非瓣膜病心房颤动病人脑梗死的影响

目的探究抗栓疗法在≥80岁非瓣膜病心房颤动(房颤)病人脑梗死中的应用效果。方法回顾性分析2014年2月至2016年7月在我院接受治疗的88例非瓣膜病心房颤动病人,根据病人是否进行抗栓治疗及服用抗栓药物的情况将病人分为抗凝组、抗血小板组和对照组,比较不同抗栓方案的治疗效果,并对其影响因素进行分析。结果抗凝组脑梗死发生率为15.63%,抗血小板组为29.41%,对照组为54.55%,差异有统计学意义(P0.05)。单因素分析结果显示,高血压、冠心病、糖尿病及慢性心功能不全、房颤时间和治疗方案与脑梗死有密切关联(P0.05);多因素Logistic分析结果显示,高血压、冠心病、糖尿病、房颤时间是房颤后脑梗死的独立危险因素,OR(95%CI)分别为2.211(1.159~4.217),1.935(1.041~3.598),1.742(1.020~2.974),1.552(1.151~2.094)(P0.05)。抗凝组皮肤瘀斑、牙龈/鼻出血、皮下血肿、上消化道出血事件发生率小于抗血小板组(P0.05)。结论房颤时间是影响非瓣膜病心房颤动病人脑梗死的独立危险因素,抗凝治疗此类病人出血风险低,对脑梗死的发生具有保护作用,超高龄病人治疗中应以抗凝治疗为主。     

老年社区人群心房颤动的患病率及相关危险因素的调查

目的研究心房颤动(AF)的患病率、危险因素及治疗情况。方法天津市5家公立福利养老院的社区老年人参加本项研究。收集基本人口学资料、既往史及个人史信息,完善体格检查和12导联心电图检查。结果对1 280名社区老年人进行了调查,资料完整可追溯的715名受访者的数据纳入统计分析,年龄为(80.6±7.9)岁(57～112岁)。AF的患病率为9.5%(68例),其中男性8.8%(28例)、女性10.1%(40例),性别之间无显著性差异(P=0.55)。最常见的合并症依次为高血压、冠心病、脑卒中、高脂血症和糖尿病。AF患者平均CHA_2DS_2-VASc评分为4.3±1.4。在68例AF患者中只有1例患者接受华法林抗凝治疗,4例接受双联抗血小板治疗(阿司匹林和氯吡格雷),9例接受单联抗血小板治疗(阿司匹林或氯吡格雷),54例未接受任何抗栓治疗。结论 AF是中国老年人的常见病。然而,社区老年AF患者治疗的问题十分突出,尤其是抗凝治疗。需要进一步促进健康措施及教育工作来提高人们对AF的认识。     

高血压合并冠心病患者抗凝和抗血小板治疗的选择

<正> 抗血小板治疗和抗凝治疗统称为抗栓治疗,常用抗血小板药物包括阿司匹林、氯吡格雷和血小板膜糖蛋白(GP)Ⅱh/Ⅲa受体拮抗剂,常用抗凝药物包括低分子肝素、肝素以及华法林。高血压是冠心病最重要的危险因素之一,抗栓治疗是冠心病预防中的主要手段。多年来,对于哪些高血压患者应该应用抗栓药物一直存在争议。合并冠心病的高血压     

心房颤动(1)心房颤动抗栓治疗的策略与进展(续前)

缺血性脑卒中是心房颤动(房颤)的主要并发症,抗栓治疗具有重要的临床意义.近年房颤抗栓治疗取得进展,包括对房颤缺血性脑卒中/血栓及出血风险的评估,抗栓策略的选择以及具有循证医学依据的新抗凝药物.房颤缺血性脑卒中危险因子包括老龄,高血压,糖尿病,心力衰竭,以及既往缺血性脑卒中/一过性脑缺血等;女性和血管疾病是目前明确的增加房颤血栓事件的高危因子.2010年欧洲心脏病协会(European Society of Cardiology,ESC)房颤管理指南以及2012年美国胸科医师协会(ACCP 9)推荐CHADS2以及CHA2DS2-VASc作为房颤缺血性脑卒中风险评分工具.CHA2DS2-VASc比CHADS2更能准确辨认真正低危的房颤患者.真正低危患者(CHA2DS2-VASc=0)可不抗栓治疗.CHA2DS2-VASc≥1的患者均应抗凝治疗,无论华法林或新的口服抗凝药物.达比加群,Rivaroxaban(利伐沙班),Apixaban(阿哌沙班)是有循证医学依据的新一代抗凝药物.     

心房颤动合并冠心病联合抗栓治疗的再探讨

长期需要口服抗凝治疗的患者中约30％合并缺血性心脏病,当这些患者接受经皮冠状动脉介入治疗(PCI)后,往往需要双联抗血小板药物治疗,此后长期抗栓治疗策略的安全性一直存在质疑和争议.从冠心病防治角度,双联抗血小板十分重要,而口服抗凝药物已经成为心房颤动预防卒中最重要的治疗措施.现有国际指南和华法林治疗的中国专家共识均建议给予口服抗凝药物联合双联抗血小板药物的所谓"三联"抗栓治疗[1-2],遗憾的是,此建议并无前瞻性临床研究证据.而且,毫无疑问这种治疗将大大增加患者的出血风险,而严重出血增加死亡率.     

心房颤动合并冠心病患者支架置入术后的抗栓治疗

约20%～30%的心房颤动患者合并冠心病,其中至少5%～7%行冠状动脉支架置入治疗。心房颤动合并冠心病患者支架置入术后需要同时抗凝和抗血小板治疗,平衡血栓事件与出血风险是制定治疗方案的关键。多项临床研究提到,口服抗凝药联合一种抗血小板药将成为三联抗栓治疗的替代治疗方案,但由于样本量不足,尚不能支撑临床决策和个人抗栓方案的制定。大规模、多中心、随机、双盲、高质量的临床试验仍有待出现。     

冠状动脉介入治疗术后伴非瓣膜性心房颤动合并缺血性脑卒中患者的抗栓治疗

目的回顾性分析经皮PCI术后伴非瓣膜性心房颤动合并缺血性脑卒中患者入院前抗凝及院内抗栓治疗情况。方法回顾性收集2011年1月1日~2014年4月31日首都医科大学附属北京安贞医院神经内科诊断为非瓣膜性心房颤动合并缺血性脑卒中患者413例,其中已行PCI患者88例(支架组),未行PCI患者325例(对照组),对比2组危险因素、合并疾病、CHA_2DS_2-VSc、抗凝治疗出血风险评估、入院前抗凝及住院期间抗栓治疗情况。支架组按住院期间是否抗凝治疗又分为抗凝组28例,非抗凝组60例,再对2组进行相同分析。结果支架组CHA_2DS_2-VSc、入院前抗凝(服用华法林)、双联抗血小板比例较对照组明显升高,入院后抗凝增加比例较对照组明显降低(11.4%vs 24.9%,P=0.006)。抗凝组单抗血小板和双联抗血小板比例明显低于非抗凝组(10.7%vs41.7%,P=0.040;0vs 48.3%,P=0.000)。结论 PCI术后伴非瓣膜性心房颤动合并缺血性脑卒中患者入院前和住院期间总体抗凝治疗比例较低。     

Antithrombotic strategies in patients with an indication for long-term anticoagulation undergoing coronary artery stenting: safety and efficacy data from a single center.

BACKGROUND: Dual antiplatelet therapy is the antithrombotic treatment generally recommended after percutaneous coronary intervention with stent implantation (PCI-S). However, the optimal antithrombotic treatment after PCI-S in case of a concomitant indication for anticoagulation (AC) is unknown. The aim of our study was to determine the strategies adopted at our Institution (where the management of these patients is at the physician's discretion), and to evaluate their relative efficacy and safety. METHODS: A retrospective analysis of all PCI-S performed between January 2002-April 2004, was carried out. All patients on AC at the time of PCI-S were identified and the hemorrhagic and thromboembolic complications recorded. RESULTS: Twenty-seven patients (21 males, 6 females, mean age 66.9 +/- 10.6 years) on AC because of atrial fibrillation, post-myocardial infarction cardiomyopathy, left ventricular or arterial thrombus, previous cerebrovascular event, and mechanical aortic or mitral valve, were identified. The adopted antithrombotic treatment included: dual antiplatelet therapy in 6 patients (22%), a combination of a single antiplatelet with either aspirin or a thienopyridine and oral AC in 5 (19%), and triple therapy with dual antiplatelet and either oral AC or low-molecular-weight heparin administration in 16 (59%). The overall complication rate at 32.3 +/- 5.4 days was 18%, accounted for by two in-hospital major hemorrhages requiring blood transfusion (7%), two minor hemorrhages treated conservatively (7%), and one subacute stent thrombosis requiring emergency percutaneous reintervention (4%). CONCLUSIONS: At our Institution, variable antithrombotic strategies are adopted after PCI-S in patients with an indication for AC. Since the overall complication rate was relevant, further properly sized and designed studies are warranted in order to identify the optimal antithrombotic treatment in this patient subset.     

老年房颤合并冠心病的抗栓方案及再住院原因分析

目的评价老年心房颤动(房颤)合并冠心病病人的抗栓治疗方案,并分析主要心血管不良事件(MACE)的发生与再住院原因。方法选取本院2013~2014年976例房颤合并冠心病病人,分成急性冠脉综合征(ACS)和稳定型冠心病(SCAD)2组并随访3年。分析2组不同卒中栓塞和出血评分下抗栓药物的选择、MACE导致再住院的发生率。结果与ACS病人首选口服双联抗血小板药物(DAPT)相比,SCAD病人更倾向于抗凝治疗(华法林或达比加群酯),2组差异有统计学意义(P<0.05)。3年随访期间,ACS组481例,115次住院,再住院率为23.9%;而SCAD组495例,176次住院,再住院率为35.5%,差异有统计学意义(P<0.05)。室性心律失常、心力衰竭及ACS是SCAD组再住院的前3位原因。心肌梗死和心力衰竭是ACS组的主要再住院原因。结论ACS合并房颤的病人主要接受DAPT治疗,而SCAD合并房颤的病人则主要行口服抗凝药物治疗。与ACS病人相比,SCAD病人有着更高的MACE发生率和再住院率。     

Anticoagulation in the elderly

Oral anticoagulation therapy has demonstrated benefit in the treatment and prevention of a variety of thromboembolic disorders. Most individuals who receive oral anticoagulant therapy are elderly patients with nonvalvular atrial fibrillation and acute or recurrent venous thromboembolism. Anticoagulation in elderly patients poses unique challenges for the practicing clinician because they are simultaneously at higher risk for recurrent thromboembolism and major bleeding, including catastrophic intracranial hemorrhage. The pharmacology of warfarin in the elderly is reviewed, including important drug interactions and current dosing recommendations for elderly patients. Evidence of the benefits and risks of oral anticoagulation therapy are reviewed for patients with atrial fibrillation and venous thromboembolism. This information should enable practitioners to better assess the relative risks and benefit of oral anticoagulation therapy to guide treatment decisions in the elderly.     

老年非瓣膜性心房颤动抗凝治疗现状分析

目的分析影响老年非瓣膜性心房颤动患者抗凝治疗的因素,为提高老年心房颤动患者抗凝治疗寻求解决方法。方法对2009-10-01—2010-04-30入住北京协和医院,年龄≥65岁的老年非瓣膜性心房颤动患者进行门诊及电话随访,观察分析全因死亡、抗凝比例、未选择抗凝的原因、抗凝终止的原因、不抗凝(抗凝终止)后的抗栓方法等指标。结果共70例连续入院的患者纳入研究,平均随访9.1个月(6.0~13.5个月)。有效随访63例,其中包括年龄<75岁组33例和年龄≥75岁组30例。失访7例(10%)。随访期间共8例(12.7%)死亡,包括年龄<75岁组1例(3%)和年龄≥75岁组7例(23.3%)。有效随访病例中,进行抗凝治疗的仅16例(25.4%),这16例中INR达标13例。8例死亡患者均未进行抗凝治疗,其中6例称大夫未交待抗凝,另2例有明确抗凝禁忌证。结论老年心房颤动患者抗凝比例低,有效抗凝率低。抗凝过程中中断的比例高。解决老年心房颤动患者抗凝过程的具体困难是有效治疗的关键。     

Anticoagulation in the elderly

This review will address the general approach to the management of the typical elderly patient requiring anticoagulation. Most of the data has been derived from studies of patients with non-valvular atrial fibrillation. Data from postmyocardial infarction trials have also been included. A practical clinical approach to anticoagulation in the elderly is described. Emphasis has been placed on maximizing the benefit and reducing the risk of anticoagulation in the rapidly expanding group of elderly patients aged ≥75 who are at the greatest risk of stroke and are likely to benefit the most from antithrombotic therapy.     

Stroke prophylaxis in institutionalized elderly patients with atrial fibrillation

OBJECTIVES: To identify patterns and predictors of antithrombotic use and to evaluate the appropriateness of antithrombotic therapy for stroke prophylaxis in institutionalized elderly patients with atrial fibrillation. DESIGN: Retrospective study. SETTING: Seventeen long-term care institutions in Edmonton, Alberta. SUBJECTS: Two hundred sixty-five long-term care residents, aged 65 and older, with atrial fibrillation. MEASUREMENTS: The proportion of patients who were prescribed warfarin, acetylsalicylic acid (ASA), both, or neither was determined. Odds ratios were calculated to identify risk factors for stroke and bleeding that are predictive of the receipt of anticoagulant therapy. Appropriateness of therapy was evaluated based on whether patients were prescribed antithrombotic therapy in accordance with their risk factors for stroke and bleeding. RESULTS: Warfarin was prescribed for 49% of patients, ASA for 22%, both for 8%, and neither for 20%. Nearly all patients (97%) were considered to be at high risk for stroke, with age being the predominant risk factor (88%>75), whereas about half were considered to be at low risk for bleeding. Multivariate analyses did not find any associations between individual risk factors for bleeding and anticoagulant treatment, with the exception of recent surgery (odds ratio=0.59, 95% confidence interval=0.37-0.94). Overall, 54.8% of patients received appropriate antithrombotic therapy. Of patients who were optimal candidates for anticoagulation, 60% received appropriate therapy (warfarin with or without ASA). CONCLUSION: Although warfarin was the most appropriate treatment in nearly all of this population at high risk for stroke, it was prescribed in fewer than two-thirds of patients. Antithrombotic therapy was not always prescribed in accordance with patients' risk factors for stroke and bleeding. There is a need for systematic identification of appropriate candidates for anticoagulation in the long-term care setting.     

重视老年心血管疾病患者抗血栓策略的选择

抗血栓治疗是防止动静脉血栓形成、也是冠心病和房颤等心血管疾病的主要治疗措施之一,对于减少血栓性事件的发生具有重要意义。然而,抗血栓治疗常会导致出血。老年患者由于其自身的生理特点,常伴发多系统疾病,血栓及出血风险都明显增加,在抗血栓治疗时宜根据患者自身病情,慎重选择抗栓策略,平衡血栓及出血风险,使患者获益最大化。     

Antithrombotic therapy in atrial fibrillation and additional stroke/embolism risk factors. CORSurvey Study]

OBJECTIVES: To evaluate 1) how many patients with atrial fibrillation (AF) and heart failure were discharged from Austrian hospitals with antithrombotic therapy, 2) if the presence of risk factors for stroke/embolism (age > 65 years, arterial hypertension, diabetes, and previous stroke) influence the choice of antithrombotic therapy and if the presence of contraindications for oral anticoagulation (dementia, alcohol abuse) influence the choice of antithrombotic therapy, and 3) if there are differences among the types of departments in the use of antithrombotic therapy. PATIENTS: Included were 1566 patients (841 female, 725 male, mean age 76 years) with AF and heart failure. METHODS: At discharge, a questionnaire was completed including risk factors, contraindications for antithrombotic therapy, and antithrombotic medication. RESULTS: Oral anticoagulants (OAC) had 26% of the cases, acetyl salicylic acid (ASA) 31%, a combination of OAC and ASA 2%, and no antithrombotic therapy 41%. The risk factors age > 65 years, arterial hypertension, diabetes, and previous stroke did not influence the choice of antithrombotic therapy. Dementia but not alcohol abuse influenced the choice against OAC. The rate of OAC was higher in cardiological or cardiovascular rehabilitation clinics than in other departments. CONCLUSION: The results of this survey show that in medical practice the recommendations regarding antithrombotic therapy in atrial fibrillation are rarely considered, especially when additional risk factors are present.