住院心房颤动患者抗凝治疗现状分析

Analysis of present situation of anticoagulation therapy in hospitalized patients with atrial fibrillation

目的了解住院心房颤动（房颤）患者抗凝治疗中存在的问题，为更加安全的抗凝治疗提供依据。方法收集2013年1月1日至8月31日在江苏省苏北人民医院心内科住院治疗的所有非瓣膜性房颤患者病历资料进行回顾性分析。根据2010年《欧洲心脏病学会（ESC）心房颤动治疗指南》，采用CHADS2-VASc评分和HAS—BLED评分分别对患者进行血栓栓塞危险程度分层和出血风险评估。主要分析指标为接受不同房颤治疗方案（室率控制，节律控制）患者的血栓栓塞危险分层，出血风险评分，抗凝药物应用情况、国际标准化比值（INR）、出血合并症、血栓栓塞事件、患者用药依从性等。结果纳入分析的患者共134例，男性69例，女性67例；年龄20～91岁，平均（67±14）岁，CHA2DS2-VASe评分为0、1和≥2分者分别为11、23和100例，HAS—BELD评分≥3分者13例。接受室率控制和节律控制治疗者分别为85和49例。接受室率控制治疗的85例患者中CHA2DS2-VASe评分为0、1、≥2分者分别为1、12、72例。0分者1例使用阿司匹林。1分者12例中2例应用华法林，2例未行抗凝治疗（1例有禁忌证），8例使用抗血小板药物（阿司匹林、氯吡格雷单用或二药联用），其中2例单用氯吡格雷患者头颅CT检查均有多发性缺血灶。≥2分者72例中33例应用华法林，35例应用抗血小板药物，4例未行抗凝治疗。接受华法林抗凝治疗的患者出院时25例INR〈2．0，7例INR为2．0～3．0，1例INR〉3．0。接受节律控制治疗的49例患者CHA2DS2-VASe评分平均为（2．3±1．8），HAS—BLED评分平均为（1．3±1．1），其中25例应用华法林，出院时17例INR〈2．0，5例INR为2．0～3．0，2例INR〉3．0。1例患者未监测INR。134例患者中有15例（11．2％）出现脑梗死，其中8例（53．3％）应用华法林抗凝治疗，患者出院时INR均未达标。结论住院房颤患者抗凝治疗中存在的主要问题是采用华法林抗凝的比例较低，采用华法林治疗的部分患者抗凝强度不足。临床医师过分担心发生出血合并症是抗凝治疗不规范的主要原因。

Objective To explore the problem of anticoagulation therapy in hospitalized patients with atrial fibrillation and obtain evidences for safer anticoagulant therapy in clinical practice. Methods The medical records of patients with non-valvular atrial fibrillation who were hospitalized in Department of Cardiology, Northern Jiangsu People＇s Hospital from January 1 to August 31, 2013 were collected and analyzed retrospectively. The patients were evaluated after risk stratification of thromboembolism and the risk of hemorrhage by CHADS2-VASc score and HAS-BLED score according to the 2010 ESC Guidelines for Management of Atrial Fibrillation. The main indicators of analysis included the patients＇ risk stratification of thromboembolism, the score of risk of hemorrhage, the situation of applying anticoagulant, international normalized ratio （INR）, hemorrhagic complication, thromboembolie events, and the compliance with medication in patients who received different therapeutic regimen of atrial fibrillation （ ventricular rate control and rhythm control）. Results A total of 134 patients were enrolled into the study, including 69 male and 67 female with an average age of（ 67 ＋ 14）years （20 to 91years）. The number of patients whose CHA2DS2- VASc score 0, 1, and 〉12 were 11, 23, and 100, respectively. The number of patients whose HAS-BELD score I〉3 was 13. The patients who received the ventricular rate control and the rhythm control therapy were 85 and 49, respectively. Among the 85 patients who received the rate control treatment, there were 1,12,72cases whose CHA2DS2-VASc scores were 0, 1, and /〉2, respectively. One patient with CHA2DS2-VASc score 0 received aspirin. Two, 8, and 2 patients with CHA2DS2-VASc score 1 received warfarin, antiplatelet drug （only aspirin, only clopidogrel or both）, and did not receive any anticoagulants （one patient had contraindication）, respectively. There were 2 patients who received only clopidogrel developed multiple focal cerebral ischemia as shown by head CT examination in the 8 patients who received antiplatelet drugs. Thirty-three, 35, and 4 patients with CHA2DS2-VASc score1〉2 received warfarin, antiplatelet drug and did not receive any anticoagulants, respectively. The cases number of INR 〈 2.0, 2.0-3.0, and 〉 3.0 were 25, 7 and 1 respectively in patients who received warfarin on discharge. The average CHA2DS2-VASc score and HAS-BLED score in 49 patients who received the rhythm control therapy were （2.3 ±1.8） and （ 1.3 ± 1.1 ） , respectively. Twenty-five patients received warfarin. The number of INR 〈 2.0, 2.0-3.0, and 〉 3.0 were 17, 5 and 2 respectively in patients who received warfarin on discharge. One patient did not monitor INR. Fifteen of 134 patients developed cerebral infarction. Among them, 8 patients （55.3%） received warfarin and none achieved INR standard on discharge. Conclusions The main problems of anticoagulation therapy in hospitalized patients with atrial fibrillation are the lower rate of receiving warfarin therapy and the lower intensity of anticoagulation treatment. Unnecessary concern of clinicians about hemorrhagic complication is the main reason of irregular anticoagulant therapy.