利伐沙班联合抗血小板药治疗同时存在心房颤动和颅内动脉狭窄的缺血性卒中患者:与单用利伐沙班的比较

Rivaxaban combined with antiplatelet drugs in ischemic stroke patients with atrial fibrillation and intracranial artery stenosis:comparison with rivaroxaban alone

目的探讨利伐沙班联合抗血小板治疗非瓣膜性心房颤动合并颅内动脉中重度狭窄的缺血性卒中患者的有效性和安全性。方法回顾性纳入2019年8月至2022年3月青岛大学附属烟台毓璜顶医院连续收治的非瓣膜性心房颤动伴颅内动脉中重度狭窄的缺血性卒中患者。根据二级预防药物分为利伐沙班组和利伐沙班联合抗血小板治疗组,比较两组基本特征。主要转归指标为3个月时卒中复发率,次要转归指标包括3个月时任何出血事件发生率、全因病死率、神经功能改善率以及转归良好率。转归良好定义为3个月时改良Rankin量表≤2分。结果研究共纳入108例患者,年龄(70.72±8.08)岁;利伐沙班组56例(51.9%),联合治疗组52例(48.1%)。在主要转归指标方面,联合治疗组3个月时卒中复发率显著低于利伐沙班组(7.69%对21.43%;P<0.05)。在次要转归指标方面,联合治疗组3个月时出血事件发生率显著高于利伐沙班组(26.92%对7.14%;P<0.05),两组各有1例死亡事件;联合治疗组转归良好率显著高于利伐沙班组(75.00%对51.79%;P=0.013)。多变量logistic回归分析显示,入院时高美国国立卫生研究院卒中量表评分是转归不良的独立危险因素(优势比1.370,95%置信区间1.057~1.776;P=0.018),而利伐沙班联合抗血小板治疗是卒中复发的独立保护因素(优势比0.203,95%置信区间0.054~0.758;P=0.018)。结论合并颅内动脉中重度狭窄的非瓣膜性心房颤动患者在发生缺血性卒中后,利伐沙班联合抗血小板治疗可降低卒中复发率,改善临床转归,但会增高出血风险。

Objective To investigate the efficacy and safety of rivaroxaban combined with antiplatelet in ischemic stroke patients with non-valvular atrial fibrillation and moderate or severe intracranial artery stenosis.Methods The consecutive ischemic stroke patients with non-valvular atrial fibrillation and moderate or severe intracranial artery stenosis admitted to Yantai Yuhuangding Hospital of Qingdao University from August 2019 to March 2022 were retrospectively included.According to the secondary prevention drugs,the patients were divided into rivaroxaban and rivaroxaban combined with antiplatelet treatment group.The basic characteristics of the two groups were compared.The primary outcome was the recurrence rate of stroke at 3 months,and the secondary outcome included the incidence of any bleeding event at 3 months,the all-cause mortality rate,the improvement rate of neurological function,and the good outcome rate.The good outcome was defined as the modified Rankin Scale≤2 points at 3 months.Results A total of 108 patients aged 70.72±8.08 years old were included in the study.There were 56 patients(51.9%)in the rivaroxaban group and 52(48.1%)in the combined treatment group.In terms of primary outcome,the recurrence rate of stroke in the combined treatment group was significantly lower than that in the rivaroxaban group at 3 months(7.69%vs.21.43%;P<0.05).In terms of secondary outcomes,the incidence of bleeding events in the combined treatment group at 3 months was significantly higher than that in the rivaroxaban group(26.92%vs.7.14%;P<0.05),with one death event in each group.The rate of good outcome in the combined treatment group was significantly higher than that in the rivaroxaban group(75.00%vs.51.79%;P=0.013).Multivariate logistic regression analysis showed that high National Institutes of Health Stroke Scale(NIHSS)score at admission was an independent risk factor for poor outcome(odds ratio 1.370,95%confidence interval 1.057-1.776;P=0.018),while the rivaroxaban combined antiplatelet treatment was an independent protective factor for stroke recurrence(odds ratio 0.203,95%confidence interval 0.054-0.758;P=0.018).Conclusion After ischemic stroke in patients with non-valvular atrial fibrillation complicated with moderate and severe stenosis of intracranial artery,rivaroxaban combined with antiplatelet treatment can reduce the recurrence rate of stroke and improve the clinical outcome,but it may increase the risk of bleeding.