中国非瓣膜性心房颤动患者华法林使用不足的相关因素分析

Analysis of significant under-usage of warfarin in patients with nonvalvular atrial fibrillation

目的:评估中国首发缺血性卒中或短暂性脑缺血发作(TIA)的已知非瓣膜性心房颤动(NVAF)患者华法林的使用情况及使用不足的相关因素。方法:从中国国家卒中登记数据库(CNSR)中连续筛选首发缺血性卒中或TIA的NVAF患者,筛选已知心房颤动和新发心房颤动患者,评估华法林在适合抗凝治疗的已知心房颤动患者中的使用比例。采用多变量logistic回归模型评估华法林使用不足的相关因素。结果:在筛选出的11 080例首发缺血性卒中或TIA患者中,有996例(9.7%)患者存在NVAF且无抗凝治疗禁忌症,其中有592例既往已知存在心房颤动。在这些患者中,只有96例(16.2%)发病前服用了华法林,496例(83.8%)发病前未服用华法林。在服用华法林的患者中,只有1例患者入院时的国际标准化比值(INR)在治疗范围(2.0～3.0)内。依据CHADS2卒中风险评分,在卒中发生前的低危心房颤动患者中,有近20.2%的患者服用了华法林,而在中危及高危患者中,华法林的服用比例分别只有15.2%和16.4%。年老的和既往存在冠心病病史的患者服用华法林的可能性较小,而发病前服用抗血小板药物的患者更有可能服用华法林。结论:CNSR中首发缺血性卒中或TIA的NVAF患者中,适宜抗凝治疗的患者存在严重的华法林使用不足,即使接受抗凝治疗,达标率也极低。如果发病前给予合适的抗凝治疗并监测,许多由心房颤动导致的卒中和TIA就可避免。

Objective： To examine the current state of warfarin usage in nonvalvular atrial fibrillation（NVAF） patients with first-ever ischemic stroke（IS） or transient ischemic attack（TIA） in China,and to analyze the factors causing such under-usage.Methods： By accessing the China National Stroke Registry（CNSR）,data on consecutive patients with known NVAF who developed first-ever IS or TIA was studied.Proportion of warfarin usage was estimated in those patients with known NVAF who should be eligible for anticoagulation therapy.Factors associated to warfarin under-usage were identified by multivariate logistic regression.Results： Of 11 080 patients with first-ever IS or TIA,996（9.7%） had NVAF and no contraindications to anticoagulation therapy and 592 of them had history of AF.Among these patients,only 96（16.2%） were on warfarin and 496（83.8%） were not.In those patients on warfarin,only 1 of his International Normalized Ratios（INRs） on admission was in the therapeutic range of 2.0~3.0.Based on the CHADS2 scores,about 20.2% low risk AF patients took warfarin,however,only 15.2% moderate and 16.4% high risk patients were on warfarin.Older patients and patients with history of coronary heart disease（CHD） were less likely to be given warfarin,while patients with history of pre-stroke antiplatelet usage were more likely to take warfarin.Conclusion： Warfarin has been significantly under-used in patients with known NVAF in China.Many strokes and TIAs caused by AF could have been prevented if warfarin was appropriately prescribed and monitored.