心房颤动合并冠心病患者抗栓治疗分析

Analysis of antithrombotic therapy in patients with atrial fibrillation and coronary heart disease

目的探讨非瓣膜病心房颤动合并冠心病患者抗栓治疗方案及华法林治疗后大出血发生情况。方法回顾性分析2005年1月至2009年12月北京同仁医院住院的非瓣膜病心房颤动合并冠心病患者134例,记录基线特征、抗凝和抗血小板治疗方案,门诊或电话随访血栓栓塞、出血及主要心脏事件发生情况。结果 134例患者年龄(73.8±7.8)岁,CHADS_2评分(2.7±0.9)分。华法林组34例[单用华法林19例(55.9%),华法林和阿司匹林或氯吡格雷联合应用15例(44.1%)];非华法林组100例[阿司匹林或氯吡格雷单用74例(74.0%),阿司匹林和氯吡格雷联合应用21例(21.0%),未用抗栓药物5例(5.0%)]。随访平均2.1年发现,主要终点事件发生37例(27.5%),其中血栓栓塞12例(8.9%),大出血2例(1.5%),主要心脏事件(包括死亡、急性心肌梗死或再次血运重建)23例(17.1%)。华法林组与非华法林组比较,血栓栓塞事件差异无统计学意义(14.7%比7.0%,P=0.18),大出血有增加趋势但差异无统计学意义(3.0%比1.0%,P=0.45)。结论心房颤动合并冠心病患者华法林治疗时大出血有增加趋势。在临床实践中这类患者抗栓治疗方案有多种选择,需要大规模临床研究确定理想的抗栓方案。

Objective To investigate antithrombotic therapy strategy in patients with nonvalvular atrial fibrillation （NVAF） and coronary heart disease （CHD） and the incidence of major bleeding in those received warfarin. Methods From January 2005 to December 2009, 134 patients with NVAF and CHD were retrospectively analyzed. Clinical characteristics and anticoagulant and antiplatelet therapy data of the patients were recorded. Patients were followed up by telephone or office visit with a mean follow up period of 2. 1 years. Thromboembolism, bleeding and major adverse cardiac events （MACE, including death, acute myocardial infarction and revascularization） were recorded. Results Mean age of the patients was （73.8 ± 7.8） years and mean CHADS2 score 2.7 ± 0. 9. Of the 134 patients, 34 patients received warfarin at discharge （warfarin group, of which 19 patients with warfarin alone and 15 with warfarin plus aspirin or clopidogrel） and 100 patients without warfarin （non-warfarin group, of which 74 patients with aspirin or clopidogrel alone, 21 patients with aspirin plus clopidogrel and 5 patients without any antithrombotic drugs）. Adverse events occurred in 37 patients （27.5%）, including thromboembohc events in 12 patients （8.9%）, major bleeding in 2 patients （ 1.5% ） and MACE in 23 patients （ 17.1% ）. Compared with non-warfarin group, the incidence of major bleeding tended to be higher in warfarin group （3.0% vs. 1.0%, P =0. 45 ）. Thromboembolic events were similar between the two groups （ 14. 7% vs. 7. 0%, P = 0. 18）. Conclusions The incidence of major bleeding tends to be higher in patients with NVAF and CHD received warfarin therapy. Further large studies are needed to determine the optimal antithrombotic therapy strategy in these patients.