艾多沙班用于非瓣膜性心房颤动抗凝治疗的研究进展

口服抗凝药物是非瓣膜性房颤患者降低血栓栓塞和卒中风险的有效治疗方法。既往临床长期应用的口服抗凝药为维生素K拮抗剂及肝素,近年来新型口服抗凝剂逐渐得到广泛应用,包括直接凝血酶抑制剂达比加群和Xa因子抑制剂如利伐沙班、阿哌沙班及艾多沙班,均可用于非瓣膜性心房颤动患者的卒中预防。艾多沙班作为新型口服抗凝剂,为房颤患者提供了更多的用药选择。本研究对艾多沙班在房颤患者抗凝预防和临床治疗中的作用进行综述。     

口服抗凝药对房颤患者的卒中预防作用

口服抗凝药是预防房颤患者卒中的有效措施,而房颤患者在伴随其他疾病等特殊情况下,将影响口服抗凝药的作用从而增大卒中或出血风险。本文将对比新型口服抗凝药及华法林对房颤患者卒中预防过程中的获益与风险,旨在为不同房颤患者的抗凝药物选择提供参考。     

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。     

牛国栋:房颤消融围手术期抗凝策略怎么选?为你支招!

正导管消融给房颤患者带来获益的同时,也增加了卒中等栓塞事件的风险,为减少血管栓塞事件进行抗凝治疗又会导致患者出血风险增加。因此,对房颤消融患者如何进行围手术期抗凝管理,一直是目前临床上十分棘手的重点难点问题,随着非维生素K拮抗剂口服抗凝药(NOACs)在非瓣膜性房颤患者抗凝治疗应用的逐渐增多,其与传统抗凝药物的对比性研究进展如何?该如何看待两者的优势和劣势?中华医学会心电生理与起搏分会青年委员会副主任委员、阜外医     

新型口服抗凝药在伴有慢性肾脏疾病的非瓣膜性房颤患者中抗凝的研究进展

心房颤动是常见的心律失常疾病,持续48 h即可形成血栓,血栓脱落可导致动脉栓塞,其中90%是缺血性脑卒中,而慢性肾脏疾病可进一步增加房颤患者的卒中和出血风险。因此,在伴有慢性肾脏疾病的非瓣膜性房颤患者中的抗凝尤为重要。华法林用于肾功能不全的房颤患者虽可减少血栓栓塞的发生率,但是随着肾功能的恶化,华法林可增加出血的风险,且维持国际标准化比值（INR）在目标范围的时间非常困难。与华法林相比,新型口服抗凝药物能显著地降低卒中、颅内出血和死亡风险。然而新型口服抗凝药物在轻度、中度、重度,甚至血液透析房颤患者的应用仍存在争议。     

非瓣膜性房颤患者抗凝治疗影响因素分析

目的 调查我院住院非瓣膜性房颤患者抗凝治疗情况,分析可能影响抗凝治疗的因素,探讨临床药师在抗凝管理中发挥的作用。 方法 收集我院住院非瓣膜性房颤患者238例,对抗凝药物选择、剂量、国际标准化比值（INR）、凝血功能监测频率、合并用药、基础疾病、出血并发症、用药教育等进行回顾性分析。 结果 我院CHA2DS2-VASc评分在2分及以上的非瓣膜性房颤患者规范抗凝覆盖率48.8%,年龄和合并冠心病会影响临床抗凝药物选择,临床药师为患者提供用药教育对患者抗凝治疗接受度影响具有显著统计学意义（p＜0.01）。出院前PT/INR在目标值范围内的患者仅占38.15%（29/76）,TTRs平均值为49.57%±3.68%。年龄、性别、华法林初始剂量、出血风险、合并用药等不影响INR达标情况,合并疾病中仅消化道疾病对INR达标间存在统计学意义（P=0.027）,住院期间患者凝血功能监测频率也影响患者INR达标率（p=0.038）。结论 目前我院非瓣膜性房颤患者的规范抗凝覆盖率仍较低,临床药师可充分利用自身专业知识,开展患者抗凝药物用药教育,积极参与到抗凝管理中,提高抗凝期间凝血功能监测频率,提高抗凝达标率,促进卒中防治效果。     

探讨非瓣膜性心房颤动的抗凝治疗

房颤是常见而顽固的房性心律失常,随着社会人口老龄化,房颤的发病率在逐年增加,房颤的病因也在变化,高血压和冠心病已经取代心脏瓣膜病成为房颤的主要病因。房颤患者因各种不适反复住院,引发心衰、卒中、猝死使房颤患者病死病残率高,远期预后较非房颤患者差。房颤已成为全球最常见的慢性非传染性疾病之一。脑卒中是房颤患者最严重的并发症,非瓣膜性房颤患者缺血性脑卒中发生率是非房颤患者的5.6倍,瓣膜性房颤患者的缺血性卒中发生率比窦律患者更是高出17倍。房颤患者一旦发生缺血性卒中,则致死致残率剧升,抗凝治疗可有效降低缺血性卒中的发生率,本文就非瓣膜性房颤的抗凝治疗做一综述。     

新型口服抗凝药在非瓣膜性房颤中的应用进展

目的:对新型口服抗凝药(NOACs)在非瓣膜性房颤抗凝治疗中的临床应用和发展进行探讨。方法:收集最新发表的相关文章,对新型口服抗凝药的药理学特性、临床试验结果和临床应用进行分析总结。结果与结论:房颤是临床中最常见的心律失常,对于CHA_2DS_2-VASc评分≥2或既往曾有一过性脑缺血发作(TIA)或有卒中史的患者,应该使用抗凝药物。新型口服抗凝药,与维生素K拮抗剂(VKA)相比,有相似甚至更好的抗凝效果、安全性和便利性。它们具有快速起效,更多可预测的药动学特征,与其他药物相互作用少,饮食对其无明显影响,比华法林导致颅内出血的风险更低。     

新型口服抗凝药物在房颤治疗及预后方面的研究进展

华法林是防治房颤卒中最有效抗凝药物。出血、频繁监测INR值等缺点限制了华法林临床使用率。新近一些新型口服抗凝药物的研究不断涌现,许多研究结果表明这些新型口服抗凝药物在预防卒中的作用中不劣于华法林,且出血风险可能较华法林低,故有望取代华法林这一传统抗凝药。本文系统回顾近年有关口服抗凝药的相关研究,并将这些研究进展综述如下。     

依达赛珠单抗逆转达比加群酯致脑出血一例药学监护

心房颤动患者常口服抗凝药预防静脉血栓栓塞和脑卒中的同时也会增加出血的风险。本文报告1例临床药师参与达比加群酯治疗非瓣膜性房颤患者致脑出血后,紧急使用依达赛珠单抗逆转的药物治疗过程,分析整个过程不良反应发生的原因及相关因素,并协助医师制订重启抗凝方案,同时实施药学监护,保障了患者安全合理用药。     

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.     

Direct oral anticoagulants and cardiovascular prevention in patients with nonvalvular atrial fibrillation

Introduction: Patients with atrial fibrillation have an increased risk for stroke, systemic embolism and cardiovascular events, including myocardial infarction and cardiovascular death. However, the majority of studies that have analyzed the efficacy of anticoagulants have been focused only on their effects on the risk of stroke.

Areas covered: The available evidence about the association between atrial fibrillation and cardiovascular disease as well as the effects of oral anticoagulation on cardiovascular death and myocardial infarction, with a particular focus on direct oral anticoagulants, was updated in this review.

Expert opinion: The management of patients with atrial fibrillation should not be limited to the prevention of stroke, but should also include the prevention of cardiovascular events. Despite treatment with vitamin K antagonists, many patients with atrial fibrillation still develop cardiovascular complications, particularly individuals whose anticoagulation is difficult to control. Direct oral anticoagulants overcome the majority of limitations of vitamin K antagonists and compared with warfarin, they lead to a greater reduction in the risk of stroke or systemic embolism, all-cause mortality, and intracranial hemorrhage. Although these drugs can only be compared indirectly, it seems that not all direct oral anticoagulants are equal with regard to the prevention of myocardial infarction.     

Timing of Initiation of Oral Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation

Patients with atrial fibrillation (AF) who suffer an acute ischemic stroke are at risk for both hemorrhagic transformation and recurrent ischemic stroke in the acute post-stroke period. Oral anticoagulants are recommended for secondary stroke prevention in patients with AF. The optimal time to initiate anticoagulant therapy after acute ischemic stroke in patients with AF is uncertain. There is concern that early initiation increases the risk of hemorrhagic transformation, whereas delayed initiation leaves the patient at risk for recurrent ischemic stroke. In this article, we provide a review of the risk of hemorrhagic transformation of acute ischemic stroke as well as review the literature and major guidelines addressing the timing of anticoagulation initiation after an acute ischemic stroke in patients with AF. Relevant articles published from 1990 to the present were identified using the PubMed and Embase databases. The majority of available literature is observational data. Large ischemic lesions, cerebral microbleeds, thrombolytic therapy, and other clinical factors may increase the risk of hemorrhagic transformation of an acute ischemic stroke. Parenteral anticoagulation within 48 hours is associated with an increased risk of hemorrhagic transformation and is not recommended. Insufficient data exist to support the safety of routine oral anticoagulant (direct oral anticoagulants or warfarin) initiation within 48 hours of an acute ischemic stroke. Direct oral anticoagulant initiation within 2 days of an acute ischemic stroke is associated with a 5% rate of hemorrhagic transformation. Infarct size and presence of hemorrhage are important factors in identifying the optimal time to initiation and should guide decisions when available. A recommended framework for patient decision making is provided. Randomized controlled trials in this area are needed to identify the optimal timing of anticoagulation initiation, and such trials are under way.     

达比加群抗凝治疗期间心房颤动患者左心耳血栓形成的原因分析

达比加群是近年来用于非瓣膜性心房颤动脑卒中预防的直接凝血酶抑制剂类新型口服抗凝血药(new oral anticoagulant,NOAC),推荐用于无禁忌证的初始抗凝治疗患者或华法林抗凝达标不佳的患者。在临床实践中,仍偶见依从性良好的心房颤动患者在使用NOAC进行规律抗凝治疗期间有左心耳血栓(left atrial appendage thrombus,LAAT)形成。这是机体本身的原因还是药物的疗效或安全性问题值得探讨。本文就规律口服达比加群抗凝治疗期间发生LAAT形成的原因进行综述与分析,为临床诊疗提供参考。     

Antiplatelet drugs in cardiovascular prevention: stroke prevention in patients with thrombogenic heart disease

(1) In patients with atrial fibrillation and a moderate embolic risk, aspirin reduces the risk of stroke and has a comparable risk-benefit ratio to oral anticoagulants. (2) Oral anticoagulants are superior to aspirin in patients with atrial fibrillation and a history of stroke. (3) In patients with a mechanical valve prosthesis and a high embolic risk, the oral anticoagulant + aspirin combination has a better risk-benefit ratio than oral anticoagulant alone.     

不同抗凝强度华法林治疗非瓣膜性房颤的安全性及缺血性脑卒中发生的危险因素评估

目的 评估华法林不同抗凝强度治疗非瓣膜性房颤的安全性,以及缺血性脑卒中发生的危险因素。方法 纳入2012年1月—2013年12月收治的130例非瓣膜性房颤患者,根据华法林抗凝治疗的强度分为中强度组：华法林中等强度抗凝治疗,国际标准化比率(international normalized ratio,INR)控制在2.0＜INR≤3.0;低强度组：华法林低等强度抗凝,INR控制在1.6≤INR≤2.0,记录2组患者治疗和随访期间缺血性脑卒中、出血栓塞等不良反应的发生率,ROC曲线法分析INR诊断抗凝出血风险,多因素Logistic回归分析患者缺血性脑卒中的危险因素。结果 中强度组缺血性脑卒中、短暂性脑缺血发作和外周动脉栓塞发生率分别为6.70%,3.45%和1.72%,与低强度组的8.33%,4.17%和4.17%比较,无统计学差异(P>0.05);中强度组华法林用量(3.13±0.45)mg·d^-1,INR值2.61±0.32,出血发生率为24.14%;低强度组华法林用量(2.63±0.32)mg·d^-1,INR值 1.84±0.30,出血发生率为9.72%。采用INR诊断患者出血风险,ROC曲线下面积为0.858(95%CI：0.791~0.924),INR的cut-off值2.85,该值下判断出血敏感性为81.1%,特异性为67.2%;多因素logistic回归分析发现年龄、合并高血压、糖尿病、心力衰竭、脑卒中病史、INR、治疗窗内时间、卒中危险评分是非瓣膜性房颤患者缺血性脑卒中发生的独立危险因素(P<0.05)。结论 中、低强度华法林抗凝治疗均有较好的抗凝效果,非瓣膜性心房颤动患者伴有血栓栓塞危险因素应尽早应用华法林抗凝治疗,严密监测INR,INR值控制在1.6≤INR≤2.0,降低和避免出血并发症。     

经皮左心耳封堵术的应用现状

非瓣膜性心房颤动相关的血栓栓塞发生率、致残率和致死率高,会极大影响患者的生活质量,而口服抗凝药物又存在出血风险高、治疗依从性差等局限性,故如何安全、有效地预防心房颤动相关的血栓栓塞一直是临床难题之一。经皮左心耳封堵术基于90%的非瓣膜性心房颤动相关血栓来源于左心耳的事实,对左心耳进行经导管的介入封堵,以替代抗凝药物预防血栓栓塞,避免抗凝药物治疗所带来的出血风险。近20年来,该技术的安全性和有效性已得到众多临床研究的证实,为需进行抗凝治疗、但合并存在抗凝药物治疗禁忌或出血风险高的非瓣膜性心房颤动患者提供了一种重要的血栓栓塞预防方法。