既往非瓣膜性心房颤动合并急性心肌梗死患者住院期间抗栓治疗研究

Study on Antithrombotic Therapy of the Hospitalized Patients with Acute Myocardial Infarction and Non-valvular Atrial Fibrillation

目的回顾性调查既往非瓣膜性心房颤动(non-valvular atrial fibrillation,NVAF)合并急性心肌梗死(acute myocardial infarction,AMI)患者抗栓治疗实际应用情况,并分析住院期间双抗治疗(阿司匹林联合氯吡格雷或替格瑞洛)基础上肠外抗凝的抗栓疗效。方法纳入首都医科大学附属北京安贞医院2010年1月-2015年12月因AMI住院且出院诊断为AMI和NVAF患者143例,其中NVAF病程≥1个月,统计抗栓治疗实际应用情况,将住院期间使用双抗治疗和肠外抗凝联合双抗治疗患者分为双抗组(33例)和三抗组(102例),比较两组间出血性事件[采用出血学术研究会(Bleeding Academic Research Consortium,BARC)出血定义]和缺血性事件(缺血性卒中、急性冠脉综合征再发和外周动脉栓塞)发生。结果 1143例入选患者仅12.6%(18/143例)入院前使用华法林抗凝治疗。住院期间,71.3%(102/143例)患者使用肠外抗凝联合双抗,部分患者未使用任何抗凝治疗,双抗占23.1%(33/143例),单抗(阿司匹林或氯吡格雷或替格瑞洛)占2.1%(3/143例)。患者出院带药中,超过2/3患者使用双抗治疗,比例占76.9%(103/134例),华法林联合双抗比例仅占4.5%(6/134例)。2住院期间双抗组相较于三抗组总出血性事件(BARC 2~5)、重大出血事件(BARC 3,5)和轻微出血事件(BARC2)发生率低(3.0%vs 7.8%,0 vs 1.0%,3.0%vs 6.9%),而缺血性事件、缺血性卒中、外周动脉栓塞的发生率高(6.1%vs 3.9%,6.1%vs 1.0%,3.0%vs 0),但两组间差异均无显著性(P>0.05)。结论本研究结果提示既往NVAF合并AMI患者住院期间部分患者未使用任何抗凝治疗,双抗基础上肠外抗凝治疗并未显著降低栓塞事件和增加出血事件,该类患者二级预防三重抗栓治疗比例很低。

Objective To investigate the application of antithrombotic therapy and analyze the effect of the antithrombotic treatment with parenteral anticoagulation and dual antiplatelet therapy （DT; aspirin＋clopidogrel/ticagrelor） in hospitalized patients with acute myocardial infarction （AMI） and non-valvular atrial ifbrillation （NVAF） retrospectively. Methods A total of 143 hospitalized patients who was admitted with AMI and diagnosed with NVAF within 1 month before admission between Jan 2010 and Dec 2015 in Department of Neurology of Beijing Anzhen Hospital were included in this study. The antithrombotic therapy information during hospitalization period and on discharge were investigated. Patients recevied DT during hospitalization period were divided into DT group （n=33） while patients recevied parenteral anticoagulation combined with DT were divided into TT group （triple antithrombotic therapy, n=102）. The bleeding events according to the bleeding academic research criteria （BARC） and ischemic events （ie, ischemic stroke, recurrent acute coronary artery syndrome, peripheral arterialembolization） were compared between the two groups. Results①Only 12.6% （18/143） of these 143 selected patients with NVAF were taking warfarin before their AMI admission. During hospitalization period, 71.3% （102/143） of those received parenteral anticoagulation combined with DT and there were some patients who didn’t receive any anticoagulant therapy, among which, DT accounted for 23.1% （33/143）, and single antiplatelet therapy （ST; aspirin/clopidogrel/ticagrelor） accounted for 2.1% （3/143）. On discharge, more than 2/3 patients received DT, accounting for 76.9% （103/134）, and only 4.5% （6/134） received warfarin combined with DT.②During hospitalization period, the rate of total bleeding events （BARC 2-5）, major bleeding events （BARC 3, 5） and minor bleeding events （BARC 2） were lower （3.0%vs 7.8%, 0vs 1.0%, 3.0%vs 6.9%）, however, the rate of total ischemic events, ischemic stroke, peripheral arterial embolism rate were higher （6.1%vs 3.9%, 6.1%vs 1.0%, 3.0%vs 0） in DT group compared with TT group, while there was no signiifcant difference between the two groups （P〉0.05）. Conclusion This study suggests that there are some patients who don’t received any anticoagulant therapy, and the parenteral anticoagulation combined with dual antiplatelet therapy does not significantly reduce the thrombotic events and increase the hemorrhagic events during hospitalization in patients with AMI and NVAF. What’s more, the proportion of the triple antithrombotic therapy as secondary prevention is very low in patients with AMI and NVAF.