单中心非瓣膜性心房颤动患者抗栓现状分析及建议

Antithrombotic Therapies for Patients with Nonvalvular Atrial Fibrillation:a Single-center Comparative Analysis and Recommendations

背景非瓣膜性心房颤动(NVAF)是临床常见的心律失常疾病,脑卒中是心房颤动(简称房颤)最常见的危害之一。目前临床研究主要集中在房颤合并冠心病抗栓方案或抗栓达标情况探讨方面,对于不同用药方案之间远期安全性及有效性的研究少有报道。目的对房颤各抗栓方案有效性及安全性、各年龄组用药方案及1年内房颤相关终点事件进行对比分析。方法选取2018年1—10月于广东省中医院心血管科住院的NVAF患者354例为研究对象,记录患者的性别、年龄、房颤类型(阵发性、永久性、持续性、长程持续性)、合并症﹝脑卒中/短暂性脑缺血发作(TIA)、心力衰竭、高血压、糖尿病、冠心病、高脂血症﹞、肌钙蛋白T(cTnT)、卒中风险评分(CHA2DS2-VASc评分)、出血风险评分(HAS-BLED评分)及随访1年内血栓栓塞事件、出血事件、全因死亡及再入院情况。按抗栓方案不同分为无抗栓组(42例)、阿司匹林组(21例)、氯吡格雷组(51例)、联合组(25例)、华法林组(49例)、达比加群组(89例)、利伐沙班组(77例),按年龄不同分为<65岁(60例)、65~75岁(92例)、>75岁(202例),并比较不同抗栓方案及年龄间各项指标有无差异。结果联合组男性占比高于无抗栓组,华法林组年龄小于氯吡格雷组,利伐沙班组阵发性房颤占比低于联合组,无抗栓组、华法林组冠心病占比低于氯吡格雷组、联合组,联合组冠心病占比高于利伐沙班组、达比加群组,联合组cTnT水平高于无抗栓组、阿司匹林组、氯吡格雷组、华法林组、利伐沙班组、达比加群组,氯吡格雷组HAS-BLED评分高于达比加群组(P<0.05)。不同抗栓方案治疗1年内总血栓栓塞事件发生率比较,差异有统计学意义(χ^(2)=12.404,P=0.054),全因死亡率比较,差异无统计学意义(χ^(2)=9.925,P=0.128)。不同抗栓方案治疗1年内总出血事件发生率比较,差异有统计学意义(χ^(2)=14.420,P=0.019)。不同年龄段患者再入院率比较,差异有统计学意义(P<0.05)。结论早期识别房颤并行抗栓治疗在预防血栓栓塞方面具有重要意义。抗栓首选新型口服抗凝药物(NOAC)或者华法林,NOAC在预防血栓形成及出血方面不劣于华法林,但需注意消化道出血风险。对于高龄房颤患者,抗凝更需个体化。

Background Nonvalvular atrial fibrillation(AF)is a common clinical arrhythmia disease,and AF-related stroke is one of its commonest complications.Available relevant clinical studies mainly focus on antithrombotic therapies or the achievement of antithrombotic goals in coronary heart disease(CHD)patients with AF,but rarely compare the long-term safety and efficacy of different therapies.Objective To compare the efficacy,safety and one-year AF-related endpoint events of different antithrombotic therapies in nonvalvular AF patients,regardless of age and by age group.Methods The included 354 nonvalvular AF inpatients were recruited from Department of Cardiovascular,Guangdong Provincial Hospital of Chinese Medicine from January to October 2018.Information was collected,including gender,age,type of AF(paroxysmal,perpetual,persistent,long-standing persistent),complications(stroke/transient ischemic attack,heart failure,hypertension,diabetes,CHD,hyperlipidemia),cTnT,CHA2DS2-VASc score,and HAS-BLED score.Also,the incidence of thromboembolic events,hemorrhagic events,all-cause deaths and readmission within one-year follow-up period was obtained.The efficacy and safety were compared between groups treated with non-antithrombotic regimen(42 cases),aspirin(21 cases),clopidogrel(51 cases),dual antiplatelet therapy(25 cases),warfarin(49 cases),dabigatran(89 cases)and rivaroxaban(89 cases).And these regimens'efficacy and safety were further analyzed based on age group﹝<65 age group(60 cases),65-75 age group(92 cases),>75 age group(202 cases)﹞.Results The proportion of men in dual antiplatelet therapy group was higher than that in non-antithrombotic regimen group(P<0.05).The average age of warfarin group was younger than that of clopidogrel group(P<0.05).Paroxysmal AF prevalence in rivaroxaban group was lower than that in dual antiplatelet therapy group(P<0.05).CHD prevalence in non-antithrombotic group was lower than that of clopidogrel group or dual antiplatelet therapy group,and so did that in warfarin group(P<0.05).CHD prevalence in dual antiplatelet therapy group was higher than that of rivaroxaban group or dabigatran group(P<0.05).The average cTnT level of dual antiplatelet therapy group was higher than that of other five groups(P<0.05).Clopidogrel group had higher average HAS-BLED score than dabigatran group(P<0.05).The groups treated with different regimens showed statistically significant differences in the incidence of thromboembolic events within one-year follow-up(χ^(2)=12.404,P=0.054).They also showed statistically obvious differences in the incidence of bleeding events within one-year follow-up(χ^(2)=14.420,P=0.019).But they demonstrated similar incidence of all-cause deaths(χ^(2)=9.925,P=0.128).The readmission rate of patients in three age groups was significantly different(P<0.05).Conclusion Early identification of AF and timely antithrombotic therapy are of great significance in preventing thromboembolism.New oral anticoagulants(NOAC)or warfarin may be the first choice for antithrombotic treatment of nonvalvular AF.NOAC is not inferior to warfarin in preventing thrombosis and bleeding,but the risk of gastrointestinal bleeding should be paid attention to.For elderly AF patients,individualized anticoagulant therapy may be more effective.