老年非瓣膜性心房颤动患者抗凝治疗质量与预后研究

Study on the quality and prognosis of long-term oral anticoagulation therapy in elderly patients with non-valvular atrial fibrillation

目的评估老年非瓣膜性心房颤动（房颤）患者使用华法林抗凝现状以及抗凝质量、效果。方法本研究为单中心注册研究，2011年8月到2012年12月我院登记注册的非瓣膜性房颤患者564例，其中老年患者（年龄65～92岁）348例（61．7％）。通过长期门诊或电话随访，对患者的抗凝状况、临床事件以及抗凝质量（抗凝治疗窗内时间）进行记录及分析。结果304例患者人组，平均随访时间为13．4个月（6～22个月），其中30．2％（92例）患者长期坚持口服华法林抗凝治疗，65～74岁组55例（35．3％），75～92岁组37例（25％）。67例（72．8％）患者定期监测国际标准化比值（INR）共记录599个INR值，平均INR为2．1，平均治疗范围内的时间百分比（TTR）为56．2％，两年龄组差异无统计学意义。75～92岁组全因死亡率8．8％（13例）高于65～74岁组2．6%（4例），P〈0．05；但与房颤相关的栓塞或出血事件死亡率差异无统计学意义。总卒中事件共11例，年发生率为3．1％，两年龄组差异无统计学意义。服用华法林组出血事件31．2％（23例）高于非华法林组11．8％（11例），P〈0．01，主要为轻微出血，两年龄组出血事件差异无统计学意义。结论老年非瓣膜性房颤患者中华法林抗凝治疗严重不足。高质量的抗凝能降低老年患者，包括75岁以上的高龄患者的血栓栓塞事件且严重出血事件无明显增加。

Objective To investigate the status of oral anticoagulation therapy （OAC） in elderly patients with non-valvular atrial fibrillation, and evaluate its quality and the curative efficacy. Methods The research was a single center registration study in a tertiary referral hospital in Beijing. We registered 564 consecutive patients with non-valvular atrial fibrillation including 348 elderly patients （61.7 %） who were over 65-years old from Aug 2012 to Dec 2013. The anticoagulation status of patients, clinical events and quality of anticoagulation treatment were documented by a long-term follow-up of all patients. Quality of anticoagulation was expressed as time in therapeutic range （TTR） calculated by the linear interpolation method. Results A total of 309 patients consisted of the cohort of study after excluding patients undergoing catheter ablation. The mean follow-up time was （13.4±4.8） months. 92 patients （30.20//00） were in long-term adherence to oral anticoagulant therapy including 55 cases （35.3%） in group aged 65-74 years and 37 cases （25.0%） in group aged 75-92 years. A total of 599 INR values from 67 patients （72.8o/00） were acquired for analysis. The mean INR was 2.1. The overall mean TTR was 56.2%. There was no significant difference in the analysis of TTR between the two groups at different ages. All-cause mortality was higher in group aged 75-92 years than in group aged 65-74 years [8.8%（13 cases） w 2.6% （4 cases）, P^0.05]. BUt no difference in mortality associating thrombotic and hemorrhagic events caused by atrial fibrillation and OAC was observed between the two age groups. The annual stroke incidence was 3. 1% （11 cases） in total population, and there was no difference in the annual stroke incidence between the two age groups. The rate of hemorrhage which mainly was minor bleeding, was higher in warfarin group than in the non-warfarin group [31.2% （34 cases） w 11.8~ （23 cases）, P^0. 011. There was no significant difference in minor or intracranial hemorrhagic events between the two age groups. Conclusions The elderly patients with non-valvular atrial fibrillation in China are inadequately treated with anticoagulation. High quality of anticoagulation significantly reduces thromboembolic events in the elderly patients, even in those above 75 years old, without increasing major bleeding events.