Use of oral anticoagulants in atrial fibrillation is highly variable and only weakly associated with estimated stroke risk: Cross-sectional population database study

Background: Current international guidelines promote the use of stroke risk stratification tools to inform decision making about oral anticoagulant (OAC) use in atrial fibrillation (AF).

Objectives: To examine (a) differences between CHADS₂ and CHA₂DS₂VASc in classifying stroke risk in a primary care population of AF patients; (b) patterns of use of antithrombotics by stroke risk; and (c) patient and practice characteristics associated with use of oral anticoagulants in patients with AF.

Methods: Cross-sectional multilevel modelling study of all patients with AF and without rheumatic heart disease or valve replacement (n = 21 564) from 315 Scottish General Practices.

Results: (a) CHADS₂ characterized 30.3% in the intermediate and 53.8% in the high-risk category, compared to CHA₂DS₂VASC only 9.7% intermediate and 85.1% high-risk. (b) Of included patients, 17.8% were currently not prescribed any antithrombotic and 43.3% were on OAC. OAC use was only weakly related to stroke risk. (c) Patients with paroxysmal AF and those with dementia and previous peptic ulcer (adjusted ORs 0.26, 0.25 and 0.79) were less likely to be prescribed OAC. OAC use varied over five-fold between practices after adjustment for patient case mix, with remote and non-training practices and those with high levels of high-risk prescribing being more likely to prescribe OAC.

Conclusion: Evidence was found of both underuse and overuse of OAC in patients with AF. Promoting instruments for stroke risk assessment in AF is a plausible but untested strategy to improve decision making in AF, and its impact on OAC prescribing and patient outcomes should be evaluated in pragmatic trials.     

老年慢性房颤患者抗栓治疗调查研究

目的探讨老年慢性房颤患者脑卒中预防。方法对我院就诊的老年慢性房颤患者资料进行随访调查,对比服用华法林和阿斯匹林药物后,患者缺血性脑卒中及脑出血并发症的发生率。结果华法林组缺血性脑卒中发病率同阿司匹林组比较显著下降;华法林组与阿司匹林组并发非致死性出血机率无统计学差异。结论对于老年慢性房颤患者缺血性脑卒中的预防,华法林比阿司匹林效果明显。     

Anticoagulant treatment of patients with chronic atrial fibrillation in primary health care in Sweden--a retrospective study of incidence and quality in a registered population

BACKGROUND: The number of patients receiving anticoagulant treatment is increasing. Chronic atrial fibrillation is the most common treatment diagnosis. The literature indicates a variable level of treatment control. Estimates of time within the therapeutic range have been recommended as a measurement of quality. Electronic patient records are providing clinical data that are useful for audits concerning anticoagulant treatment in real-life practice. OBJECTIVE: Our aim was to assess warfarin treatment for chronic atrial fibrillation in primary health care with regard to prevalence, incidence and quality. METHODS: A 2 year retrospective study was carried out of electronic patient records up to April 2002 in primary health care in Stockholm, including 12 primary health care centres with a registered population of 203 407. Main outcome measures were the number of new patients on wafarin treatment for chronic atrial fibrillation, and time within the therapeutic prothrombin range in the first 90 days of treatment using a linear interpolation method. RESULTS: In total, 827 patients were on warfarin treatment for chronic atrial fibrillation, giving a prevalence of 0.41%. Of these, 144 patients (study group) started treatment with warfarin for chronic atrial fibrillation during the study period, giving a yearly incidence of 0.07%. Their mean age was 73.1 years and 61.1% were men. There were 1721 prothrombin monitoring episodes registered in the first 90 days of treatment, on average once a week per patient. The average proportion of time within the therapeutic range was 54.1% (95% confidence interval (CI) 50.1-58.1), and the proportion of therapeutic tests was 50.2% (95% CI 47.8-52.6). CONCLUSIONS: During the first, second and third months of warfarin treatment for chronic atrial fibrillation, patients were outside the therapeutic range time nearly half the time. There was a gender difference favouring men regarding initiation of treatment.     

Role of hospitalists in the diagnosis of atrial fibrillation for the management of cryptogenic stroke patients

Cryptogenic strokes are responsible for significant morbidity and mortality. Identifying the underlying cause of cryptogenic stroke is imperative for appropriate short and long-term management of these patients. In particular, detecting atrial fibrillation in cryptogenic stroke patients may shed insight into the cause of the index stroke, but is also important to identify an important cause of secondary stroke. There is accumulating evidence indicating that monitoring for durations beyond the guideline recommended 30 day-period results in greater atrial fibrillation yield. This article reviews current guidelines and practices for the diagnosis of cryptogenic stroke, as well as outpatient cardiac monitoring options available, and focuses on the role that hospitalists have to play in the care of these patients.     

阵发性心房颤动导管射频消融的护理

本文报告了2例阵发性心房颤动导管射频消融肺静脉电隔离术的围术期护理.介入治疗前有针对性地做好心理护理,落实各项术前准备措施;术中医护密切配合;术后即刻护理,密切监测患者生命体征,术后健康指导和并发症的观察与处理是围术期护理的关键.     

The WATCHMAN device for stroke prophylaxis in atrial fibrillation: an evolving niche

Atrial fibrillation is associated with a markedly increased risk of thromboembolic stroke. At present, lifelong antithrombotic therapy with warfarin or a novel oral anticoagulant is indicated for prophylaxis in the majority of patients. Left atrial appendage occlusion devices have been developed as an alternative to these agents, aiming to avoid issues around consistency of anticoagulation, bleeding risk, and drug-related side effects. The best evidence is available for Boston Scientific’s WATCHMAN device. The safety and efficacy of WATCHMAN and other similar devices have been questioned, although the increasing body of evidence supports a role in selected settings. A recently updated randomized controlled trial of WATCHMAN (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation [PROTECT-AF]) demonstrates its noninferiority to warfarin and suggests an advantage in terms of functional outcome for patients, with superior net clinical benefit 6 to 9 months after starting treatment. The procedural risk associated with device implantation remains substantial, although improving device design and increasing operator experience means that this should decrease in the future. As the body of data and overall experience around WATCHMAN grow, it may come to be recognized as the best option in selected patients.     

Differences in quality of care among patients hospitalized with atrial fibrillation as primary or secondary cause for admission.

OBJECTIVE: Several factors have been linked to the variation in the quality of care for patients with atrial fibrillation (AF). Whether hospitalization primarily for AF (primary diagnosis of AF) as opposed to another primary diagnosis but having concomitant AF (secondary diagnosis of AF) impacts quality of care for AF is not known. Accordingly, we sought to evaluate the differences in quality of care of Medicare patients admitted with primary diagnosis versus secondary diagnosis of AF. DESIGN AND SETTING: We studied a random sample of Medicare fee-for-service discharges from Michigan's acute care hospitals over a 1-year period with a primary or secondary diagnosis of AF (ICD-9-CM 427.31). Main outcome measure. Warfarin use at the time of discharge. RESULTS: Of 5993 patients in the study, 772 had a primary diagnosis of AF and 5221 had a secondary diagnosis of AF. Patients with a secondary diagnosis of AF were older, more likely to be male, and less likely to be hypertensive. Patients with a secondary diagnosis of AF 'ideal' for anticoagulation (n = 1648) were less likely to receive warfarin compared with 'ideal' patients with primary diagnosis of AF (n = 363) (52.6% versus. 59.8%, P < 0.001). Adherence to test indicators was lower in patients with secondary diagnosis of AF. CONCLUSION: Secondary diagnosis of AF rather than AF as a primary diagnosis appears to account for most Medicare patients with AF admitted to hospitals. Whereas quality of care is lower in patients with secondary diagnosis of AF, opportunity for quality improvement exists for both groups of patients with AF.     

Addressing between‐study heterogeneity and inconsistency in mixed treatment comparisons: Application to stroke prevention treatments in individuals with non‐rheumatic atrial fibrillation

Mixed treatment comparison models extend meta‐analysis methods to enable comparisons to be made between all relevant comparators in the clinical area of interest. In such modelling it is imperative that potential sources of variability are explored to explain both heterogeneity (variation in treatment effects between trials within pairwise contrasts) and inconsistency (variation in treatment effects between pairwise contrasts) to ensure the validity of the analysis. The objective of this paper is to extend the mixed treatment comparison framework to allow for the incorporation of study‐level covariates in an attempt to explain between‐study heterogeneity and reduce inconsistency. Three possible model specifications assuming different assumptions are described and applied to a 17‐treatment network for stroke prevention treatments in individuals with non‐rheumatic atrial fibrillation. The paper demonstrates the feasibility of incorporating covariates within a mixed treatment comparison framework and using model fit statistics to choose between alternative model specifications. Although such an approach may adjust for inconsistencies in networks, as for standard meta‐regression, the analysis will suffer from low power if the number of trials is small compared with the number of treatment comparators. Copyright © 2009 John Wiley & Sons, Ltd.     

华法林预防非瓣膜性心房颤动患者脑梗死的临床研究

目的 探讨华法林预防非瓣膜性心房颤动(NVAF)患者并发脑梗死的疗效和安全性.方法 选择NVAF患者136例,按随机数字表法分为华法林组[口服华法林钠片,初始剂量为2.0mg/d,目标国际标准化比值(INR)为2.0～3.0]、阿司匹林组(口服阿司匹林100 mg/d)和对照组(未用抗栓药物).常规门诊随访,调整华法林剂量并记录三组患者的终点事件和不良反应发生情况,随访时间18个月.结果 136例患者失访4例,进入研究的132例患者中,男77例,占58.3%.华法林组口服华法林钠片的剂量为(2.5±1.0)mg.随访期间共发生主要终点事件12例,其中华法林组1例(2.50%,1/40)、阿司匹林组4例(9.52%,4/42)、对照组7例(14.00%,7/50),三组主要终点事件发生率比较差异无统计学意义(x2=2.084,P=0.353).伴随≥3种危险因素的三组之间生存曲线比较差异有统计学意义(x2=6.404,P=0.041).华法林组出血并发症发生率高于阿司匹林组[5.00%(2/40)比2.38%(1/42)],但差异无统计学意义(P＞0.05).结论 伴随≥3种危险因素的NVAF患者,华法林可改善患者的生存率,华法林导致出血并发症多数发生在INR＞3.0.严密监测下(INR 2.0～3.0)的调整剂量华法林安全有效.     

南京市某社区≥50岁人群房颤危险因素的病例对照研究

目的  探讨江苏南京某社区≥50岁人群发生心房颤动的危险因素。 方法  2019年3月1日至4月30日,对南京市栖霞区某社区医院进行健康检查的社区老年人群开展流行病学现况调查,经12导联心电图诊断后的房颤患者为病例组,按照年龄、性别进行1:4频数匹配后的非房颤人群作为对照组。采用单因素和多因素条件Logisitc回归分析模型分析心房颤动可能的危险因素。 结果  共调查3 444名社区老人,男女性别比为1:2,房颤检出率为1.19%。单因素条件Logistic回归分析模型分析结果提示：血尿酸(OR=1.01, 95% CI: 1.00~1.01)、红细胞比容(OR=1.11, 95% CI: 1.01~1.23)、红细胞分布宽度(OR=1.50, 95% CI: 1.05~2.14)可能是房颤的危险因素。多因素条件Logistic回归分析模型分析结果显示：红细胞比容每升高1%,个体发生房颤的风险增加13%(OR=1.13, 95% CI: 1.01~1.27);红细胞分布宽度每升高1%,个体发生房颤的风险可能增加61%(OR=1.61, 95% CI: 1.00~2.59)。 结论  红细胞比容、红细胞分布宽度增加可能是南京社区老年人群房颤发生的可疑危险因素。本研究的结论需要进一步扩大样本验证。     

Risk of stroke and heart failure attributable to atrial fibrillation in middle-aged and elderly people: Results from a five-year prospective cohort study of Japanese community dwellers

Background

The relative and absolute risks of stroke and heart failure attributable to atrial fibrillation (AF) have not been sufficiently examined.

新发房颤患者缺血性卒中风险不同方法评估

目的比较CHADS₂和CHA₂DS₂-VASc 2种评分方法对心房颤动(房颤)人群的缺血性脑卒中风险评估的差异。方法采用前瞻性队列研究方法,对143例新发非瓣膜性房颤患者,用CHADS₂和CHA₂DS₂-VASc 2种评分方法进行卒中风险评估,比较2种评估方法得分以及卒中危险分层的差异。结果CHADS₂平均得分为(1.51±1.28)分,CHA₂DS₂-VASc平均得分为(2.36±1.97)分,后者明显高于前者(P<0.01);CHA₂DS₂-VASc评分低危组19例(13.3%),低于CHADS₂评分低危组的46例(32.2%)(χ²=11.21,P<0.01);CHA₂DS₂-VASc评分中危组的32例(22.4%),低于CHADS₂评分中危组42例(29.4%)(χ²=4.57,P<0.01);CHA₂DS₂-VASc评分高危组的92例(64.3%),高于CHADS₂评分高危组55例(38.5%)(χ²=20.76,P<0.01);CHADS₂评分法中,低度、中度、高度风险组,脑卒中发生例数分别为1、2、3例;CHA₂DS₂-VASc评分法中,低度、中度、高度风险组脑卒中发生例数分别为0、0、6例。结论与CHADS₂评分法比较,CHA₂DS₂-VASc评估卒中风险中、低危组比例降低,高危组比例升高。     

老年心房颤动159例临床分析

目的分析老年人心房颤动病因、临床特点和抗凝治疗的状况。方法选择1998年至今在我院住院的患者，年龄〉65岁，有心房颤动史159例，观察心电图、动态心电图、超声心动图及甲状腺功能的血清学检查等，对患者的临床资料进行回顾性分析。结果老年心房颤动病因复杂，多数伴有基础疾病或全身其他疾病。基础疾病依次为：冠心病71例（44．65％），高血压病37例（23．27％），老年性瓣膜病13例（8．18％）。病因不明38例（23．89％）。老年心房颤动患者中持久性房颤比率高（73．58％）。心房颤动患者血栓栓塞事件发生率为31．06％。结论老年人心房颤动常见原因是冠心病、高血压性心脏病。老年心房颤动患者中持久性房颤比率高。血栓栓塞是房颤的重要并发症，抗凝治疗应得到重视。     

老年人非风湿性心房颤动伴发缺血性脑卒中的相关因素分析

目的研究老年人非风湿性心房颤动（NRAF）的临床特点和NRAF伴发缺血性脑卒中的相关因素。方法回顾性分析240例NRAF老年患者的心电图、超声心动图、颈动脉彩色多普勒超声、头颅CT或磁共振等检查及临床资料。结果卒中组高血压的患病率高于非卒中组（69.39％VS52．36％,P〈0．05）;卒中组糖尿病合并高血压的患病率高于非卒中组（22.45％VS10．47％,P〈0．05）;持续性房颤患者卒中的发生率高于阵发性房颤者（24．82％VS14．14％,P〈0．05）;颈动脉有粥样硬化斑块者卒中的发生率高于无斑块者（26．26％VS10．53％,P〈0．05）;在119例轻度左房增大（内径31-40mm）患者中,二尖瓣返流（MR）者卒中发生率显著低于无MR者（4．76％VS26．53％．P〈0．05）。结论老年人NRAF伴缺血性脑卒中的独立危险因素包括：高龄、高血压、颈动脉粥样硬化斑块、糖尿病合并高血压和持续性房颤,轻度左房增大伴MR的NRAF患者缺血性脑卒中发生率较低。     

Feasibility and acceptability of opportunistic screening to detect atrial fibrillation in Aboriginal adults

Objective : Examine the feasibility and acceptability of an electrocardiogram (ECG) attached to a mobile phone (iECG) screening device for atrial fibrillation (AF) in Aboriginal Controlled Community Health Services (ACCHS) and other community settings. Methods : Semi‐structured interviews were conducted with ACCHS staff in urban, rural and remote communities in three Australian states/territories. Quantitative and qualitative questions identified the enabling factors and barriers for staff and Aboriginal patients' receptiveness to the device. Mean quantitative scores and their standard deviation were calculated in Microsoft Excel and qualitative questions were thematically analysed. Results : Eighteen interviews were conducted with 23 staff across 11 ACCHS. Quantitative data found staff were confident in providing iECG screening and managing the referral pathway, and thought the process was beneficial for patients. Qualitative data highlighted the usefulness of the device to undertake opportunistic screening and acceptability in routine practice, and provided opportunities to engage patients in education around AF. Conclusion : The iECG device was well accepted within ACCHSs and was feasible to use to screen for AF among Aboriginal patients. Implications for public health : The device can be used in clinical and community settings to screen Aboriginal people for atrial fibrillation to help reduce rates of stroke and other cardiovascular diseases.