非瓣膜性房颤患者脑梗死急性期抗凝治疗时机分析

Timing of anticoagulation after acute ischemic stroke in patients with nonvalvular atrial fibrillation

目的:调查济宁医学院附属医院非瓣膜性房颤患者脑梗死急性期启动抗凝治疗的时机,为抗凝策略提供参考。方法:采取回顾性病例研究方法,抽取该院2019年1月1日至2019年12月31日出院、诊断为急性脑梗死(或短暂性脑缺血发作)和非瓣膜性房颤的患者为研究对象,记录患者启动抗凝治疗距脑梗死症状出现的时间,并采集相关的临床资料。分别评价抗凝时机与指南推荐的"4-14"标准和"1-3-6-12"法则的符合情况。采用SPSS 23.0分析抗凝时机的影响因素。结果:共收集170例患者资料,患者平均年龄74岁(51~95岁);CHA2DS2-VASc评分均≥3分;81例患者HAS-BLED评分≥3分。依据"4-14"标准和"1-3-6-12"法则,分别有44.71%和46.90%的患者抗凝时机较指南推荐存在延迟。依据"4-14"标准分组(0~3 d、4~14 d和>14 d),组间比较显示出血史(P=0.032)、新诊断房颤(P=0.005)、新发出血(P=0.029)、影像学显示脑干梗死(P=0.034)或颅内出血(P=0.007)、会诊建议抗凝(P=0.000)、患方拒绝抗凝(P=0.001)和CHA2DS2-VASc评分(P=0.010)有统计学差异。依据"1-3-6-12"法则分组(0~1 d、2~3 d、4~6 d、7~12 d和>12 d),组间比较显示新诊断房颤(P=0.015)、会诊建议抗凝(P=0.000)、患方拒绝抗凝(P=0.013)和CHA2DS2-VASc评分(P=0.012)有统计学差异。结论:与指南推荐相比,目前抗凝时间有待进一步提前。颅内出血转化、高CHA2DS2-VASc评分、新诊断房颤的患者抗凝时间延迟,会诊医生和患方的支持有助于抗凝时间提前。

OBJECTIVE To provide references for anticoagulant strategy by examining timing of initiating anticoagulation in patients with acute ischemic stroke and nonvalvular atrial fibrillation(AF)at a tertiary hospital.METHODS From January 1,2019 to December 31,2019,a retrospective case study were conducted for patients discharged with acute ischemic stroke(or transient ischemic attack)and nonvalvular atrial fibrillation.Timing from ischemic stroke onset to start of anticoagulation as well as the relevant clinical data were recorded.The compliance of anticoagulation timing with the"4-14"standard and"1-3-6-12"rule was evaluated.SPSS 23.0 software was utilized for analyzing the influencing factors of anticoagulation timing.RESULTS A total of 170 eligible patients were selected with an average age of 74(51-95)years.CHA2 DS2-VASc score≥3 and HAS-BLED score≥3(n=81).On the basis of“4-14”standard and“1-3-6-12”rule,there were respectively 44.71%and 46.90%of patients with delayed anticoagulant therapy.The comparison of groups(0-3,4-14 and>14 days)divided according to the“4-14”standard was conducted and significant differences existed in hemorrhagic history(P=0.032),newly diagnosed AF(P=0.005),new hemorrhage(P=0.029),brainstem infarction(P=0.034),intracranial haemorrhage(P=0.007),anticoagulation recommendation from consultants(P=0.000),patients’refusal to anticoagulant therapy(P=0.001)and CHA2 DS2-VASc score(P=0.010).The comparison of groups(0-1,2-3,4-6,7-12 and>12 days)according to the“1-3-6-12”rule was also conducted and significant differences existed in newly diagnosed AF(P=0.015),anticoagulation recommendation from consultants(P=0.000),patients’refusal to anticoagulant therapy(P=0.013)and CHA2 DS2-VASc score(P=0.012).CONCLUSION Compared to guideline recommendations,timing to start anticoagulation should be earlier.Intracranial hemorrhage,high CHA2 DS2-VASc score and newly diagnosed AF lead to delay of anticoagulation while supports of consultants and patients contribute to earlier anticoagulation.