CAS评分和CHA_(2)DS_(2)-VASc评分指导我国非瓣膜性心房颤动患者抗凝治疗的预后比较

A comparison of CAS risk model and CHA_(2)DS_(2)-VASc risk model in guiding anticoagulation treatment in Chinese patients with non-valvular atrial fibrillation

目的比较CAS和CHA_(2)DS_(2)-VASc评分两种卒中风险评估模型预测非瓣膜性心房颤动(房颤)患者全因死亡、血栓栓塞、大出血事件以及复合终点发生方面的差异。方法本研究为回顾性队列研究。从中国房颤注册研究(CAFR)中,选取年龄>18岁的非瓣膜性房颤患者,随机分为CAS评分组和CHA_(2)DS_(2)-VASc评分组,并根据基线和随访过程中抗凝状态筛选出2组中依从评分规范抗凝的患者纳入本研究。收集并比较两组患者的年龄、性别等基本信息,并定期进行随访,随访内容包括是否接受抗凝治疗以及终点事件。终点事件为全因死亡、血栓栓塞和大出血事件,复合终点事件为全因死亡和血栓栓塞事件。分析CAS评分组和CHA_(2)DS_(2)-VASc评分组相关终点事件发生情况,并采用多因素Cox比例风险模型比较两组相关终点事件发生率的差异。结果共纳入5206例房颤患者,年龄(63.6±12.2)岁,女性2092例(40.2%)。其中CAS评分组2447例(47.0%),CHA_(2)DS_(2)-VASc评分组2759例(53.0%)。CAS组左心室射血分数<55%、非阵发性房颤、口服华法林比例以及HAS-BLED评分低于CHA_(2)DS_(2)-VASC组,而既往糖尿病病史和抗血小板药物服药史比例高于CHA_(2)DS_(2)-VASC组,其余基线资料差异无统计学意义。随访(82.8±40.8)个月,CAS评分组中有225例(9.2%)发生全因死亡,186例(7.6%)发生血栓栓塞事件,81例(3.3%)发生大出血事件,368例(15.0%)发生复合终点事件。CHA_(2)DS_(2)-VASc评分组有261例(9.5%)发生全因死亡,209例(7.6%)发生血栓栓塞事件,112例(4.1%)发生大出血事件,424例(15.4%)发生复合终点事件。两组患者在全因死亡、血栓栓塞、大出血事件以及复合终点事件发生方面差异均无统计学意义(log-rank P值分别为0.643、0.904、0.126、0.599)。Cox多因素回归分析结果也显示,两组患者在全因死亡、血栓栓塞、大出血事件以及复合终点发生方面差异均无统计学意义,HR值(95%CI)分别为0.95(0.80~1.14)、1.00(0.82~1.22)、0.83(0.62~1.10)、0.96(0.84~1.11),P均>0.05。结论在中国非瓣膜性房颤患者中,CAS评分和CHA_(2)DS_(2)-VASc评分在预测全因死亡、血栓栓塞事件以及大出血事件方面效价相同。

Objective To compare the differences between CAS risk model and CHA_(2)DS_(2)-VASc risk score in predicting all cause death,thromboembolic events,major bleeding events and composite endpoint in patients with nonvalvular atrial fibrillation.Methods This is a retrospective cohort study.From the China Atrial Fibrillation Registry cohort study,the patients with atrial fibrillation who were>18 years old were randomly divided into CAS risk score group and CHA_(2)DS_(2)-VASc risk score group respectively.According to the anticoagulant status at baseline and follow-up,patients in the 2 groups who complied with the scoring specifications for anticoagulation were selected for inclusion in this study.Baseline information such as age and gender in the two groups were collected and compared.Follow-up was performed periodically to collect information on anticoagulant therapy and endpoints.The endpoints were all-cause death,thromboembolism events and major bleeding,the composite endpoint events were all-cause death and thromboembolism events.The incidence of endpoints in CAS group and CHA_(2)DS_(2)-VASc group was analyzed,and multivariate Cox proportional risk model was used to analyze whether the incidence of the endpoints was statistically different between the two groups.Results A total of 5206 patients with AF were enrolled,average aged(63.6±12.2)years,and 2092(40.2%)women.There were 2447 cases(47.0%)in CAS risk score group and 2759 cases(53.0%)in CHA_(2)DS_(2)-VASc risk score group.In the clinical baseline data of the two groups,the proportion of left ventricular ejection fraction<55%,non-paroxysmal atrial fibrillation,oral warfarin and HAS BLED score in the CAS group were lower than those in the CHA_(2)DS_(2)-VASc group,while the proportion of previous diabetes history and history of antiplatelet drugs in the CAS group was higher than that in the CHA_(2)DS_(2)-VASc group,and there was no statistical difference in other baseline data.Patients were followed up for(82.8±40.8)months.In CAS risk score group,225(9.2%)had all-cause death,186(7.6%)had thromboembolic events,81(3.3%)had major bleeding,and 368(15.0%)had composite endpoint.In CHA_(2)DS_(2)-VASc risk score group,261(9.5%)had all-cause death 209(7.6%)had thromboembolic events,112(4.1%)had major bleeding,and 424(15.4%)had composite endpoint.There were no significant differences in the occurrence of all-cause death,thromboembolic events,major bleeding and composite endpoint between anticoagulation in CAS risk score group and anticoagulation in CHA_(2)DS_(2)-VASc risk score group(log-rank P=0.643,0.904,0.126,0.599,respectively).Compared with CAS risk score,multivariable Cox proportional hazards regression models showed no significant differences for all-cause death,thromboembolic events,major bleeding and composite endpoint between the two groups with HR(95%CI)0.95(0.80-1.14),1.00(0.82-1.22),0.83(0.62-1.10),0.96(0.84-1.11),respectively.All P>0.05.Conclusions There were no significant differences between CAS risk model and CHA_(2)DS_(2)-VASc risk score in predicting all-cause death,thromboembolic events,and major bleeding events in Chinese patients with non-valvular atrial fibrillation.