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山东大学学报 (医学版) ›› 2021, Vol. 59 ›› Issue (10): 49-67.doi: 10.6040/j.issn.1671-7554.0.2021.0394

• 临床医学 • 上一篇    下一篇

1 430例中年中危血栓栓塞风险心房颤动抗凝治疗的方案

黄柏松1,丛洪良2   

  1. 1. 天津医科大学研究生院, 天津 300070;2. 天津市胸科医院心内科, 天津 300222
  • 发布日期:2021-10-15
  • 通讯作者: 丛洪良. E-mail:hongliangcong@126.com

Anticoagulant therapy of non-valvular atrial fibrillation in 1,430 middle-aged patients with moderate-risk thromboembolism

HUANG Bosong1, CONG Hongliang2   

  1. 1. Graduate School, Tianjin Medical University, Tianjin 300070, China;
    2. Department of Cardiology, Tianjin Chest Hospital, Tianjin 300222, China
  • Published:2021-10-15

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摘要： 目的 评估CHA2DS2-VASc评分为中危血栓栓塞风险非瓣膜性心房颤动(房颤)中年患者是否接受抗凝治疗的疗效获益与安全风险,探讨抗凝治疗的合理性及不同新型抗凝剂效果对比。 方法 纳入天津市胸科医院心内科2018年9月至2020年8月诊治的符合研究标准的CHA2DS2-VASc评分=1分的男性和CHA2DS2-VASc评分=2分的女性非瓣膜性房颤中年患者1 430例,根据抗凝治疗与否及抗凝剂种类非随机分为利伐沙班组(n=476)、达比加群组(n=464)和未抗凝治疗组(n=490),回顾性分析患者临床及随访资料,比较6~30个月后终点结局指标的差异。 结果 3组基线临床资料的多因素Logistic回归分析显示,排除3组已知心血管危险因素(包括性别、年龄、房颤类型、房颤病程、HAS-BLED评分、既往病史、合并抗血小板药物)成为影响抗凝治疗与否和临床复合终点事件结局之间相关性的临床混杂因素(P>0.05)。利伐沙班组和达比加群组的临床复合终点事件发生率低于未抗凝治疗组(利伐沙班组:OR=0.400,95%CI:0.103~0.717,P<0.001;达比加群组:OR=0.458,95%CI:0.094~0.841,P<0.001),而药物累计出血事件发生率高于未抗凝治疗组(利伐沙班组:OR=3.204,95%CI:1.190~5.235,P<0.001;达比加群组:OR=4.173,95%CI:1.864~6.494,P<0.001),且利伐沙班组和达比加群组的轻微出血比例高于未抗凝治疗组(利伐沙班组:OR=2.628,95%CI:1.538~3.734,P<0.001;达比加群组:OR=2.759,95%CI:2.005~3.525,P<0.001),其他出血事件严重程度分型比例均差异无统计学意义(大出血:χ2=1.680,P=0.432;小出血:χ2=2.888,P=0.236)。单因素Kaplan-Meier生存分析显示,组间无临床复合终点事件结局累积发生率比较差异有统计学意义(χ2=19.216, P<0.001)。 结论 接受抗凝治疗对于CHA2DS2-VASc评分为中危血栓栓塞风险非瓣膜性房颤中年患者可提高临床净获益和改善近远期预后,利伐沙班和达比加群的抗凝效果相似,需谨慎选择不抗凝治疗。

关键词: 非瓣膜性心房颤动, 中年人, CHA2DS2-VASc评分, 抗凝治疗

Abstract: Objective To explore the rationality of anticoagulant therapy and compare different oral anticoagulants by evaluating the benefits and risks of anticoagulant therapy for the middle-aged non-valvular atrial fibrillation patients with moderate-risk CHA2DS2-VASc score. Methods A total of 1,430 middle-aged males with CHA2DS2-VASc score of 1 and females with CHA2DS2-VASc score of 2 diagnosed and treated in the Department of Cardiology of Tianjin Chest Hospital during Sep. 2018 and Aug. 2020 were enrolled in this retrospective study. According to whether the patients received anticoagulant therapy and the type of anticoagulants they used, the patients were divided into three groups: the rivaroxaban group(n=476), dabigatran group(n=464), and non-anticoagulant therapy group(n=490). The clinical and follow-up data were analyzed to compare differences in the endpoint outcome indicators after 6-30 month followed-up. Results Multivariate Logistic regression analysis of baseline data showed that the known cardiovascular risk factors(including gender, age, type and duration of atrial fibrillation, HAS-BLED score, medical history and antiplatelet drugs)were excluded as the clinical confounding factors influencing the correlation between anticoagulant therapy and endpoint outcomes(P>0.05). The incidence of the clinical endpoint outcomes in the rivaroxaban group and dabigatran group was lower than that in the non-anticoagulant therapy group(rivaroxaban group: OR=0.400, 95%CI: 0.103-0.717, P<0.001; dabigatran group: OR=0.458, 95%CI: 0.094-0.841, P<0.001); the incidence of drug-caused accumulative bleeding events was higher(rivaroxaban group: OR=3.204, 95%CI: 1.190-5.235, P<0.001; dabigatran group: OR=4.173, 95%CI: 1.864-6.494, P<0.001); the incidence of mild bleeding was higher(rivaroxaban group: OR=2.628, 95%CI: 1.538-3.734, P<0.001; dabigatran group: OR=2.759, 95%CI: 2.005-3.525, P<0.001). There were no statistically significant differences in the incidence of other bleeding events among the three groups(major bleeding: χ2=1.680, P=0.432; minor bleeding: χ2=2.888, P=0.236). Univariate Kaplan-Meier survival analysis showed that there was statistical difference in the cumulative incidence of non-clinical endpoint outcomes among the three groups(χ2=19.216, P<0.001). Conclusion Anticoagulant therapy can improve the net clinical benefits and short-term and long-term prognosis. Rivaroxaban and dabigatran anticoagulant therapy have similar anticoagulant effects. Therefore, non-anticoagulant therapy needs to be chosen carefully.

Key words: Non-valvular atrial fibrillation, Middle-aged, CHA2DS2-VASc score, Anticoagulant therapy

中图分类号: 

  • R541.7
[1] 国家心血管病医疗质量控制中心专家委员会心房颤动专家工作组. 2019年中国心房颤动医疗质量控制报告[J]. 中国循环杂志, 2020, 35(5): 427-437. Working Group on Atrial Fibrillation, National Center for Cardiovascular Quality Improvement(NCCQI). 2019 Clinical performance and quality measures for atrial fibrillation in China [J]. Chinese Circulation Journal, 2020, 35(5): 427-437.
[2] Joseph PG, Healey JS, Raina P, et al. Global variations in the prevalence, treatment, and impact of atrial fibrillation in a multi-national cohort of 153,152 middle-aged individuals [J]. Cardiovasc Res, 2021, 117(6): 1523-1531.
[3] Mayet M, Vallabh K, Hendrikse C. Low prevalence of atrial fibrillation in ischemic stroke: Underestimating a modifiable risk factor [J]. Afr J Emerg Med, 2021, 11(1): 39-45.
[4] Fauchier L, Lecoq C, Clementy N, et al. Oral anticoagulation and the risk of stroke or death in patients with atrial fibrillation and one additional stroke risk factor: the Loire valley atrial fibrillation project [J]. Chest, 2016, 149(4): 960-968.
[5] Jaakkola S, Kiviniemi TO, Nuotio I, et al. Usefulness of the CHA2DS2-VASc and HAS-BLED scores in predicting the risk of stroke versus intracranial bleeding in patients with atrial fibrillation(from the FibStroke study)[J]. Am J Cardiol, 2018, 121(10): 1182-1186.
[6] Yan SB, Li Q, Xia Z, et al. Risk factors of thromboembolism in nonvalvular atrial fibrillation patients with low CHA2DS2-VASc score [J]. Medicine, 2019, 98(8): e14549.
[7] Chao TF, Liu CJ, Wang KL, et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score(beyond sex)receive oral anticoagulation? [J]. J Am Coll Cardiol, 2015, 65(7): 635-642.
[8] Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European association for cardio-thoracic surgery(EACTS): the task force for the diagnosis and management of atrial fibrillation of the European society of cardiology(ESC)developed with the special contribution of the European heart rhythm association(EHRA)of the ESC [J]. Eur Heart J, 2021, 42(5): 373-498.
[9] Miura K, Shimada T, Ohya M, et al. Prevalence of the academic research consortium for high bleeding risk criteria and prognostic value of a simplified definition[J]. Circ J, 2020, 84(9): 1560-1567.
[10] Varona JF, Seguí-Ripoll JM, Lozano-Duran C, et al. Health-related quality of life in nonvalvular atrial fibrillation patients with controlled or uncontrolled anticoagulation status [J]. Heal Qual Life Outcomes, 2020, 18(1): 383.
[11] Riesinger L, Wakili R, Dobrev D. Stroke prevention of atrial fibrillation: Improving geographic under-use of contemporary antithrombotic approaches remains a challenge [J]. Int J Cardiol, 2021, 34: 100785. doi: 10.1016/j.ijcha.2021.100785.
[12] Savino JA, Halperin JL. Should patients with atrial fibrillation and 1 stroke risk factor(CHA2DS2-VASc score 1 in men, 2 in women)be anticoagulated? The CHA2 DS2-VASc 1 conundrum: decision making at the lower end of the risk spectrum [J]. Circulation, 2016, 133(15): 1504-1511.
[13] Friberg L, Skeppholm M, Terént A. Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1 [J]. J Am Coll Cardiol, 2015, 65(3): 225-232.
[14] Lip GYH, Skjth F, Rasmussen LH, et al. Net clinical benefit for oral anticoagulation, aspirin, or No therapy in nonvalvular atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score(beyond sex)[J]. J Am Coll Cardiol, 2015, 66(4): 488-490.
[15] Chan YH, Wu LS, Chang SH, et al. Young male patients with atrial fibrillation and CHA2DS2-VASc score of 1 may not need anticoagulants: a nationwide population-based study [J]. PLoS One, 2016, 11(3): e0151485.
[16] Chao TF, Liu CJ, Wang KL, et al. Using the CHA2DS2-VASc score for refining stroke risk stratification in ‘low-risk’ Asian patients with atrial fibrillation [J]. J Am Coll Cardiol, 2014, 64(16): 1658-1665.
[17] Lip GYH, Nielsen PB, Skjth F, et al. The value of the European society of cardiology guidelines for refining stroke risk stratification in patients with atrial fibrillation categorized as low risk using the anticoagulation and risk factors in atrial fibrillation stroke score: a nationwide cohort study [J]. Chest, 2014, 146(5): 1337-1346.
[18] Chiang CE, Okumura K, Zhang S, et al. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation [J]. J Arrhythm, 2017, 33(4): 345-367.
[19] 白颖, 王建旗, 史旭波, 等. 非瓣膜性心房颤动患者的抗凝治疗情况及影响因素分析[J]. 中国医药, 2021, 16(1): 19-23. BAI Ying, WANG Jianqi, SHI Xubo, et al. Analysis of anticoagulant therapy status and influencing factors in patients with nonvalvular atrial fibrillation [J]. China Medicine, 2021, 16(1): 19-23.
[20] Suzuki S, Yamashita T, Okumura K, et al. Incidence of ischemic stroke in Japanese patients with atrial fibrillation not receiving anticoagulation therapy - pooled analysis of the Shinken database, J-RHYTHM registry, and Fushimi AF registry [J]. Circ J, 2015, 79(2): 432-438.
[21] Zemedikun DT, Gray LJ, Khunti K, et al. Patterns of multimorbidity in middle-aged and older adults: an analysis of the UK biobank data [J]. Mayo Clin Proc, 2018, 93(7): 857-866.
[22] Ohsawa M, Okamura T, Tanno K, et al. 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 [J]. J Epidemiol, 2017, 27(8): 360-367.
[23] Sulzgruber P, Wassmann S, Semb AG, et al. Oral anticoagulation in patients with non-valvular atrial fibrillation and a CHA2DS2-VASc score of 1: a current opinion of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Council on Stroke[J]. Eur Heart J Cardiovasc Pharmacother, 2019, 5(3): 171-180.
[24] Lip GYH, Skjth F, Nielsen PB, et al. Non-valvular atrial fibrillation patients with none or one additional risk factor of the CHA2DS2-VASc score. A comprehensive net clinical benefit analysis for warfarin, aspirin, or no therapy [J]. Thromb Haemost, 2015, 114(4): 826-834.
[25] 丁征, 王莹, 彭昆, 等. 抗凝门诊非瓣膜性心房颤动患者口服抗凝药物出血发生情况分析[J]. 中国循环杂志, 2019, 34(10): 956-960. DING Zheng, WANG Ying, PENG Kun, et al. Analysis of bleeding in patients with non-valvular atrial fibrillationon treated with oral anticoagulants in an anticoagulantion outpatient clinic [J]. Chinese Circulation Journal, 2019, 34(10): 956-960.
[26] Gabilondo M, Loza J, Pereda A, et al. Quality of life in patients with nonvalvular atrial fibrillation treated with oral anticoagulants [J]. Hematology, 2021, 26(1): 277-283.
[27] Steffel J, Collins R, Antz M, et al. 2021 European heart rhythm association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation [J]. Europace,2021: euab065. doi:10.1093/europace/euab065.
[28] Rome BN, Gagne JJ, Avorn J, et al. Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: a population-based cohort study [J]. Am Heart J, 2021, 233: 109-121. doi: 10.1016/j.ahj.2020.12.010.
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