早期国际标准化比值对老年心房颤动患者华法林抗凝过度的预测价值

Predictive value of early international normalized ratio for Warfarin overanticoagulation in elderly patients with atrial fibrillation

目的探讨早期国际标准化比值(INR)水平与接受华法林治疗的老年心房颤动患者抗凝过度的关系,评价其预测接受华法林治疗的老年心房颤动患者抗凝过度的临床价值。方法回顾性纳入接受华法林治疗的老年心房颤动患者470例,均分别在用药3 d和7 d后的次日清晨检测INR,按照用药7 d后INR是否>3.0,将患者分为抗凝过度组(107例)和非抗凝过度组(363例)。分析两组患者的一般临床资料,使用受试者工作特征曲线(ROC)评价用药3 d INR(早期INR)水平预测接受华法林治疗的老年心房颤动患者抗凝过度的价值,采用Logistic回归方程分析接受华法林治疗的老年心房颤动患者抗凝过度的相关因素。结果抗凝过度组患者年龄、初始华法林剂量、早期INR、血清天门冬氨酸转移酶水平均高于非抗凝过度组(均P<0.05);初始华法林剂量≥2.5 mg、年龄≥70岁、体重≤65 kg、瓣膜病型房颤、低蛋白血症、肝功能异常、联用抗菌药物比例均高于非抗凝过度组(均P<0.05);抗凝过度组患者体重、血清白蛋白水平均低于非抗凝过度组(均P<0.05),合并糖尿病比例低于非抗凝过度组(P<0.05)。ROC曲线显示早期INR预测抗凝过度的AUC为0.927(95%CI:0.900~0.949,P<0.0001),灵敏度为82.86%,特异度为88.43%;此时预测抗凝过度的最佳界值早期INR≥1.66。多因素Logistic回归显示,早期INR水平≥1.66(OR=33.871,P<0.001)、初始华法林剂量≥2.5 mg(OR=17.062,P=0.011)、体重≤65 kg(OR=2.824,P=0.002)、年龄≥70岁(OR=2.678,P=0.003)、肝功能异常(OR=2.091,P=0.022)是老年心房颤动患者华法林抗凝过度的相关危险因素。结论早期INR水平与老年心房颤动患者华法林抗凝过度密切相关,可将其视为1种华法林抗凝过度的预测因子,应注意监测接受华法林治疗的老年心房颤动患者早期INR水平以降低抗凝过度事件的发生率。

Objective To investigate the relationship between early international normalized ratio(INR)and overanticoagulation in elderly patients with atrial fibrillation(AF)treated with Warfarin,and to evaluate its clinical value in predicting overanticoagulation.MethodsA total of 470 elderly patients with AF treated with Warfarin for anticoagulation were enrolled retrospectively.INR was detected in the morning of the next day after 3 days and 7 days of Warfarin treatment.According to whether INR was greater than 3.0 after 7 days of Warfarin treatment,the patients were divided into over-anticoagulation group(n=107)and non-over-anticoagulation group(n=363).The general clinical data of the two groups were analyzed.The receiver operating characteristic curve(ROC)was used to evaluate the value of 3-day INR(early INR)level in predicting overanticoagulation.Logistic regression was used to analyze the factors related to overanticoagulation in elderly AF patients receiving Warfarin treatment.ResultsThe age,initial warfarin dose,early INR and serum aspartate transferase level in the over-anticoagulation group were higher than those in the non-over-anticoagulation group(P<0.05 for all).The proportions of patients with initial Warfarin dose≥2.5 mg,age≥70 years old,body weight≤65 kg,valvular atrial fibrillation,hypoproteinemia,abnormal liver function,and combined use of antibiotics were higher in the over-anticoagulation group than those in the non-over-anticoagulation group(P<0.05 for all).The body weight,serum albumin level and the proportion of diabetes mellitus in the over-anticoagulation group were lower than those in the non-over-anticoagulation group(P<0.05).ROC curve showed that the area under the curve(AUC)of early INR in predicting over-anticoagulation was 0.927(95%CI:0.900-0.949,P<0.0001),the sensitivity was 82.86%and the specificity was 88.43%,the optimal cutoff value for predicting overanticoagulation was INR≥1.66.Multiple Logistic regression analysis showed that early INR level≥1.66(OR=33.871,P<0.001),initial warfarin dose≥2.5 mg(OR=17.062,P=0.011),body weight≤65 kg(OR=2.824,P=0.002),age≥70 years old(OR=2.678,P=0.003),and abnormal liver function(OR=2.091,P=0.022)were related factors for over-anticoagulation in elderly patients with atrial fibrillation.ConclusionsEarly INR level is closely related to overuse of anticoagulation in elderly AF patients receiving Warfarin treatment,which can be regarded as a predictor of overuse of anticoagulation.Early INR level in elderly AF patients receiving warfarin treatment should be monitored to reduce the incidence of anticoagulant overuse.