高血压病史及血压水平对非瓣膜性心房颤动患者血栓栓塞事件的影响

Impact of history of hypertension and blood pressure levels on the risk of thromboembolism in nonvalvular atrial fibrillation patients

目的探讨高血压病史及血压水平对非瓣膜性心房颤动(NVAF)患者血栓栓塞事件的影响。方法该研究的病例来自中国心房颤动注册研究,2011年8月至2018年12月于北京市31家医院前瞻性纳入了心房颤动(房颤)患者25512例。排除瓣膜性房颤、肥厚型心肌病、基线接受抗凝或导管消融治疗的患者后,最终该研究纳入患者7757例。随访终点为血栓栓塞事件,包括缺血性卒中和系统性栓塞。采用多因素Cox回归模型分析高血压病史、血压水平是否为NVAF患者发生血栓栓塞事件的独立危险因素。结果研究随访(35±25)个月,随访结束时455例(5.9%)患者发生血栓栓塞事件。有高血压病史的NVAF患者血栓栓塞事件发生率高于无高血压病史的NVAF患者(2.38/100人年比1.35/100人年,χ2=16.8,Log-rankP<0.001)。基线收缩压<120 mmHg(1 mmHg=0.133 kPa)(n=1619)、120~129 mmHg(n=2023)、130~139 mmHg(n=1728)和≥140 mmHg(n=2172)的NVAF患者栓塞事件发生率依次升高,分别为1.44/100人年、1.79/100人年、2.16/100人年和2.52/100人年(χ2=17.9,Log-rankP<0.001)。基线舒张压<70 mmHg(n=1128)、70~79 mmHg(n=2277)、80~89 mmHg(n=2804)和≥90 mmHg(n=1328)的NVAF患者栓塞事件发生率差异无统计学意义(χ2=0.6,Log-rankP=0.907)。多因素Cox回归分析结果显示,校正了CHA2DS2-VASc评分中除高血压以外的因素后,高血压病史是NVAF患者发生血栓栓塞事件的独立危险因素(HR=1.28,95%CI 1.01~1.62,P=0.040);进一步校正了房颤类型以及使用抗血小板药物、他汀类药物后,高血压病史仍然是NVAF患者发生血栓栓塞事件的独立危险因素(HR=1.27,95%CI 1.01~1.61,P=0.045)。校正了CHA2DS2-VASc评分中除高血压以外的因素后,收缩压≥140 mmHg是NVAF患者发生血栓栓塞事件的独立危险因素(HR=1.37,95%CI 1.02~1.82,P=0.035);进一步校正了房颤类型以及使用抗血小板药物、他汀类药物后,收缩压≥140 mmHg仍然是NVAF患者发生血栓栓塞事件的独立危险因素(HR=1.36,95%CI 1.02~1.82,P=0.036);而收缩压120~129 mmHg和130~139 mmHg不是NVAF患者发生血栓栓塞事件的危险因素(分别为,HR=1.23,95%CI 0.90~1.67,P=0.193;HR=1.30,95%CI 0.95~1.77,P=0.098)。舒张压不是NVAF患者发生血栓栓塞事件的危险因素(P均>0.05)。结论高血压病史及收缩压≥140 mmHg是NVAF患者发生血栓栓塞事件的独立危险因素,积极地将收缩压控制在140 mmHg以下或可降低此类患者的血栓栓塞风险。

Objective To investigate the impact of history of hypertension and blood pressure levels on the thromboembolism risk in the setting of nonvalvular atrial firillation(NVAF).Methods China Atrial Fibrillation Registry Study prospectively enrolled 25512 atrial fibrillation(AF)patients between August 2011 and December 2018.After exclusion of patients with valvular AF,hypertrophic cardiomyopathy,receiving anticoagulation or ablation therapy at the enrollment,7757 patients were included in analysis.The primary endpoint was the time to the first occurrence of ischemic stroke or systemic embolism.Cox proportional hazards models were performed to evaluate whether a history of hypertension or blood pressure levels were independently associated with thromboembolism.Results During a mean follow up of(35+25)months,455(5.9%)thromboembolic events occurred.The crude incidence rate of thromboembolism in patients with a history of hypertension was higher than that in patients without hypertension(2.38 vs.1.35 per 100 patient-years,x2=16.8,Log-rank P<0.001).Patients were further divided into 4 groups according to systolic blood pressure(SBP)levels at baseline,the crude incidence rate of thromboembolism significantly increased in proportion to the elevation of SBP levels[x2=17.9,Log-rank P<0.001].However,there was no significant difference in thromboembolism risk among 4 groups stratified by diastolic blood pressure(DBP)levels(x2=0.6,Log-rank P=0.907).Multivariable regression analysis showed that history of hypertension was independently associated with a 27%higher risk of thromboembolism(HR=1.27,95%CI 101-1.61,P=0.045).Patients with SBP>140 mmHg(1 mmHg=0.133 kPa)was associated with 36%higher risk of thromboembolism than patients with SBP<120 mmHg(HR=1.36,95%CI 1.02-1.82,P=0.036).However,patients with SBP 120-129 mmHg or 130-139 mmHg were not at a higher risk of thromboembolism as compared to the patients with SBP<120 mmHg(SBP 120-129 mmHg:HR=1.23,95%C10.90-1.67,P=0.193;SBP 130-139 mmHg:HR=1.30,95%C10.95-1.77,P=0.098).In addition,DBP levels were not independently associated with the increased thromboembolism risk.Conclusion A history of hypertension and SBP≥140 mmHg are independent predictors of thromboembolism risk in patients with NVAF.These results indicate that intensive efforts to lower SBP below 140 mmHg might be an important strategy to reduce the risk of stroke in patients with NVAF.