不同起始剂量华法林在老年非瓣膜性房颤缺血性脑卒中预防中的应用

The application of defferent initial dose of Warfarin in ischaemic stroke prevention in aged patients with nonvalvular atrial fibrillation

目的探讨老年非瓣膜性房颤患者应用华法林抗凝治疗的合适方案，以及影响治疗的因素。方法把96例65岁以上非瓣膜性房颤患者随机分为普通（3．0mg／d）、低（1．5mg／d）起始剂量组，抗凝强度的目标——国际标准化比值（INR）为1．5～3．0。随访2年。在治疗前、治疗期间查凝血酶原时间（PT）和INR。治疗前和治疗1、2年做头颅CT检查。比较两组全程缺血性脑卒中事件（“事件”）和出血的发生率，并对年龄、华法林起始用量等9个因素进行Logistic回归分析，找出血并发症的影响因素。结果96例患者平均年龄（74．5±6．8）岁，两组在随访期内均未发生“事件”；INRmax平均INR、PTmax以及出血发生率差异无统计学意义。并发出血16例（16．7％），严重出血2例（2．1％）。所有患者平均INR为（1．9±1．4）～（2．1±0．8），INRmax中位数2．4；第1个月平均实际检测次数为（4．1±1．1）次。Logistic回归分析显示，首月实际INR监测次数是出血发生的独立影响因素（OR 0．38，95％CI 0．20-0．75，P=0．006），与出血并发症呈负相关。结论低抗凝强度华法林治疗对高龄、南方非瓣膜性房颤患者预防脑栓塞是可行的。避免出血并发症，增加患者治疗依从性的重要措施是在治疗的第1个月严密监测INR，并调整用药剂量。

Objective To investigate the proper protocol of anticoagulation with warfarin to prevent isehaemic stroke in the aged patients with nonvalvular atrial fibrillation. Methods 96 patients were randomized into low-initial-dose group（1.5 rag/d） and normal-initial-dose group （3.0mg/d）, the target intensity of antieoagulation, international ormalized ratio（INR） were range from 1.5-3.0. Patients were going to follow up tow years. Prothrombin Time （PT） and INR were tested at pre-treatment and in-treatment. Cerebral Computer tomography （CT） was taken before, after one and tow year of treatment. Ischaemic stroke and hemorrhage event （ ＂event＂ ） rate were compared between tow groups. Logistic analysis for the influeneing factor of hemorrhage was taken among the nine issues including age andinitial dose. Results The average age of 96 patients were （74.5±6.8） years old. There were no ＂events＂ in the period of follow-up in two groups. There was no significant statistic difference in maximum INR,mean value INR,maximum PT and hemorrhage event rate between two groups. Hemorrhage occurred in 16 （16.7%） of total patients, which including 2（2.1%） serious hemorrhage patients. In total patients, mean INR was from （1.9±1.4） to （2.1±0.8） （range：0.5-2.9）, the median INR was 2.4. The average times of test of INR were （4.1±1.1） in the first month of treatment. Logistic analysis shown that： the times of assess of INR in the first month of treatment is an independent effecter for hemorrhage （OR 0.38, 95%CI 0.20-0.75 ,P=0.006）. Conclusion Low-intensity anticoagulation with warfarin is effective to prevent ischaemic stroke in the aged patients of south China with nonvalvular atrial fibrillation. The important method for preventing hemorrhage and enhancing the compliance of treatment using warfarin are to take more times of INR test in the first month of treatment and adjusting the warfarin＇s doses according INR.