非瓣膜性心房颤动患者的抗凝治疗情况及影响因素分析

Analysis of anticoagulant therapy status and influencing factors in patients with nonvalvular atrial fibrillation

目的探讨首都医科大学附属北京同仁医院非瓣膜性心房颤动患者抗凝治疗情况及影响因素。方法收集首都医科大学附属北京同仁医院2018年1—6月收治390例非瓣膜性心房颤动患者的临床资料,根据患者住院期间是否抗凝治疗分为非抗凝组(169例)和抗凝组(221例)。比较2组患者的男性比例、年龄、吸烟史、饮酒史、付费方式、入住心血管科情况、应用抗血小板药物情况、心房颤动类型、CHA2DS2-VASc评分和卒中风险、HAS-BLED评分和出血风险、合并疾病、住院期间治疗及用药情况和肌酐清除率。结果抗凝组221例患者中应用华法林60例(27.1%)、达比加群酯119例(53.8%)、利伐沙班42例(19.0%)。抗凝组入住心血管科比例、未应用抗血小板药物、持续性心房颤动分型、卒中评分中危、合并高脂血症、外周动脉粥样硬化、肺栓塞/深静脉血栓比例,行射频消融术、合并使用胺碘酮、地高辛、质子泵抑制剂,肌酐清除率>60 ml/min比例高于非抗凝组,而应用1或2种抗血小板药物,阵发性心房颤动,合并冠心病(冠状动脉粥样硬化性心脏病)、癌症、感染性疾病、低蛋白血症、慢性阻塞性肺疾病,合并使用抗感染药物、激素类药物、抗血小板药物(阿司匹林、氯吡格雷、替格瑞洛),以及肌酐清除率<15 ml/min比例均低于非抗凝组(均P<0.05)。心房颤动中高危卒中风险患者抗凝治疗率为56.9%(214/376),抗血小板治疗率为30.9%(116/376),无任何抗栓治疗率为12.2%(46/376)。高危组110例患者仅抗血小板药物治疗、中危组3例替代抗凝治疗为治疗不当。卒中风险低危组2例(0.5%)患者应用抗血小板药物为过度治疗。结论首都医科大学附属北京同仁医院目前非瓣膜性心房颤动住院患者抗凝治疗率与指南推荐存在一定差距。纠正可干预因素、定期动态评估血栓栓塞风险及出血风险,加强非心血管科医师专业知识培训,有助于提高非瓣膜性心房颤动住院患者抗凝治疗率,降低血栓栓塞风险。

Objective To investigate the status of anticoagulant therapy and its influencing factors in patients with nonvalvular atrial fibrillation in Beijing Tongren Hospital,Capital Medical University.Methods The clinical data of 390 patients with nonvalvular atrial fibrillation admitted to Beijing Tongren Hospital,Capital Medical University from January to June 2018 were collected.They were divided into non-anticoagulant group(169 cases)and anticoagulant group(221 cases)according to whether anticoagulant therapy was performed during hospitalization.The male proportion,age and its distribution,smoking history,drinking history,payment method,admission to cardiovascular department,application of antiplatelet drugs,atrial fibrillation classification,CHA2 DS2-VASc score and stroke risk,HAS-BLED score and bleeding risk,comorbidities,therapy and medication during hospitalization and creatinine clearance rate were compared between the two groups.Results Of the221 patients in anticoagulant group,60 cases(27.1%)were treated with warfarin,119 cases(53.8%)with dabigatran and 42 cases(19.0%)with rivaroxaban.The proportion of admission to cardiovascular department,no use of antiplatelet drugs,classification of persistent atrial fibrillation,moderate risk stroke score,combined with hyperlipidemia,peripheral atherosclerosis,pulmonary embolism/deep vein thrombosis ratios,radiofrequency ablation,combined use of amiodarone,digoxin,proton pump inhibitors and creatinine clearance rate>60 ml/min in anticoagulation group were higher than those of the non-anticoagulant group,but application of one or two antiplatelet drugs,paroxysmal atrial fibrillation,coronary heart disease,cancer,infectious disease,hypoproteinemia,chronic obstructive pulmonary disease,combined use of anti-infective drugs,hormone drugs,antiplatelet drugs(aspirin,clopidogrel,ticagrelor),and creatinine clearance rate<15 ml/min in anticoagulant group were lower than those in non-anticoagulant group(all P<0.05).The anticoagulant treatment rate was 56.9%(214/376),the antiplatelet treatment rate was 30.9%(116/376),and the no antithrombotic therapy rate was 12.2%(46/376)in atrial fibrillation patients with medium and high risk of stroke.There were only 110 patients with antiplatelet treatment in high risk group,3 paitents received inappropriate alternative anticoagulation in intermediate risk group and 2 patients(0.5%)overtreated with antiplatelet drugs in low risk stroke group.Conclusion There is a certain gap between the anticoagulant treatment rate of nonvalvular atrial fibrillation in patients from Beijing Tongren Hospital,Capital Medical University and the guidelines recommendation.Correct intervention factors,evaluate the risk of thromboembolism and bleeding,strengthen the professional knowledge training of non-cardiovascular doctors are helpful to improve the anticoagulant treatment rate of patients with nonvalvular atrial fibrillation and reduce the risk of thromboembolism.