Aortic valve stenosis provides complementary information to bleeding risk scores in non-valvular atrial fibrillation patients initiating anticoagulation

Background The identification of modifiable bleeding risk factors may be of relevance.The aim is to evaluate if aortic stenosis(AS)provides additional information to bleeding risk scores for predicting major bleeding(MB)in non-valvular atrial fibrillation(AF).Methods We designed a retrospective multi-center study including 2880 consecutive non-valvular AF patients initiating oral anticoagulation between January 2013 and December 2016.AS was defined as moderate or severe according to European echocardiography guidelines criteria.HASBLED,ATRIA and ORBIT scores were used to evaluate the bleeding risk.MB was defined according to the International Society on Thrombosis and Haemostasia criteria and registered at 18 months of follow-up.Results 168(5.8%)patients had AS.Patients with AS had higher risk for MB compared to those without AS(HR=2.13,95%CI:1.40-3.23,P<0.001).Patients without AS and low-intermediate bleeding risk(0 points)showed the lowest MB rate,whereas the MB rate observed among patients with AS and high bleeding risk(2 points)was the highest one.Discrimination and reclassification analyses showed that AS provided additional information to bleeding risk scores for predicting MB at 18 months of follow-up.Conclusions In this population,AS was associated with an increased risk for MB at midterm follow-up.The three scoring systems showed a moderate discriminatory ability for MB.Moreover,the addition of AS was associated with a significant improvement in their predictive accuracy.We suggest that the presence of this valvulopathy should be taken into account for bleeding risk assessment.

Rate of anticoagulant use, and factors associated with not prescribing anticoagulant in older Thai adults with non-valvular atrial fibrillation: A multicenter registry

Objectives To investigate the rate of anticoagulant use,the reasons for not prescribing anticoagulant,and the factors associated with non-prescription of anticoagulant in older Thai adults with non-valvular atrial fibrillation.Methods A multicenter registry of patients with non-valvular atrial fibrillation was conducted during 2014 to 2017 in Thailand.Demographic,medical history,antithrombotic medication,non-antithrombotic medication,and laboratory data were collected and analyzed.Data were compared between the older adult (≥ 65 years) and younger adult (< 65 years) groups.The reasons why anticoagulant was not prescribed were collected,and predictive factors were identified.Results A total of 3218 patients (1873 males) with an average age of 67.3 ± 11.3 years were included.Almost two-thirds (61.0%) of patients were in the older adult group.Anticoagulant was prescribed in 2422 patients (75.3%): 81.4% in the older adult group and 65.7% in the younger adult group.The three main reasons for not prescribing anticoagulant were already taking antiplatelets,patient refusal,and bleeding risk.These reasons were more common in older adults as compared to younger adults.Multivariate analysis revealed current use of antiplatelets to be the most important factor that predict the non-prescription of anticoagulant in older population.Conclusions The prevalence of anticoagulant prescription among older Thai adults with atrial fibrillation is 81.4%.Taking antiplatelet drugs was found to be the strongest reason that predicts the non-prescription of anticoagulant in this patient population.A guideline should be developed to optimize the use of anticoagulant and antiplatelet in older adults.

Analysis of the Impact Factors on a Stable Warfarin Dose in Extreme Elderly (Age ≥ 80 Years) Chinese Patients with Non-Valvular Atrial Fibrillation

Purpose: The aim of this study was to investigate non-genetic and genetic factors contributing to stable warfarin dose change in the extreme elderly patients with non-valvular atrial fibrillation. Methods: A total of 40 elderly patients with stable warfarin doses were included in this study. Clinical basic data, such as age, sex, body mass index, basic disease like hypertension, diabetes and coronary heart disease had been recorded. Two nucleotide polymorphisms about VKORC1-1639G^A and CYP2C9 1075A^C genes were detected via sequencing by hybridization. Results: The elderly patients with CYP2C9 1075A^C (CA) genotype needed less warfarin daily doses than those?with CYP2C9 1075A^C (AA) genotype (1.93 ± 0.79 mg/d VS 2.15 ± 0.64 mg/d), but there was no significant difference (p = 0.601). While the daily warfarin dose required for patients with VKORC1-1639G^A (AA) genotype was significantly lower than that for patients with VKORC1-1639G^A (GA) genotype (2.00 ± 0.67 mg/d VS 2.63 ± 0.38 mg/d, p = 0.012). VKORC1-1639G^A together with age and diabetes status accounted 41.7% for dose variability. The new algorithm was developed using multivariate linear regression analysis;the model was developed for: Dose = 7.731 – 0.056 * age + 0.527 * DM - 0.785 * VKORC1. Conclusions: VKORC1-1639G^A together with age and diabetes status might predict warfarin doses in age ≥ 80 years patients with non-valvularatrial fibrillation. In contrast, the polymorphism of CYP2C9 1075A^C was not associated with dose variability.

Atrial Myocardial Deformation Changes in Patients with Non-Valvular Atrial Fibrillation

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia. It increases cardiovascular morbidity, especially embolic stroke and mortality. Two-dimensional speckle tracking echocardiography (2D STE) is a useful method that has been used to detect changes in atrial myocardial deformation in AF patients. Objectives: To study atrial myocardial deformation changes in patient with non-valvular AF using 2D STE. Patients and Methods: This study included 25 patients with non-valvular AF and 25 normal healthy controls. 2D STE was used for assessment of strain and strain rate of septal and free walls of both right atrium (RA) and LA and left ventricle (LV). Results: Mean LA septal and lateral strain and strain rate were significantly reduced in the AF group compared to the control group (-7.2% ± 5.2% vs. -20.4% ± 3.9%, -8.7% ± 8.8% vs. -21.7% ± 3.4%) and (-0.9 ± 0.5 S-1 vs. -1.9 ± 0.4 S-1, –1.1 ± 0.6 S-1 vs. -2.04 ± 0.3 S-1) respectively. Mean RA septal and lateral strain and strain rate were significantly reduced in the AF group compared to the control group (-5.9% ± 6.1% vs. -23.4% ± 4.5%, -8.9% ± 9.3% vs. -21.7% ± 3.4%) and (-0.98 ± 0.6 S-1 vs. -1.9 ± 0.3 S-1, -1.3 ± 0.9 S-1 vs. -2.1 ± 0.5 S-1) respectively. Mean LV global longitudinal strain (GLS) and strain rate were significantly reduced in the AF group compared to the control group (-8.8% ± 4.6% vs -19.6% ± 2.4%) and (-0.8 ± 0.3 S-1 vs -1.5 ± 0.4 S-1) respectively (P < 0.001 for all). Conclusion: AF is a bi-atrial disease, LA and RA myocardial deformation properties as well as LV GLS and strain rate measured by 2D STE were significantly impaired in AF patients compared to healthy controls.

TLR2 was overexpressed independent of IL-6 in patients with valvular atrial fibrillation

Toll-like receptor 2 （TLR2） has recently been shown to be up-regulated in patients with non-valvular atrial fi-brillation （AF）. The present study was aimed to determine whether the pathogenesis and development of AF is associated with the up-regulation of TLR2. Clinical data and right atrial appendage （RAA） specimens were col-lected from 20 patients with persisten AF （PeAF）, 15 patients with paroxysmal AF （PaAF） and 13 patients with no history of AF undergoing valvular replacement. The results showed that gene expression and protein content of TLR2 were increased in both the AF subgroups, compared with the sinus rhythm （SR） group. Between the two AF subgroups, PaAF had a higher TLR2 level than PeAF. However, no difference in interluekin （IL）-6 content was found among the three groups, and no correlation was found between TLR2 and IL-6 in PeAF patients （r = 0.090, P = 0.706）, PaAF patients （r = 0.408, P = 0.131） and AF patients （r = -0.301, P = 0.079）. Immunohistochemical analysis revealed that TLR2 was distributed in RAAs of AF patients and confirmed the immunoblotting results. In conclusion, we demonstrated that TLR2 was elevated in AF （especially PaAF） patients with valvular heart disease, further implicating inflammation involved in the pathogenesis and development of AF.

Bioinformatics Analysis on lncRNA and mRNA Expression Profiles for Novel Biological Features of Valvular Heart Disease with Atrial Fibrillation

The biological features of the valvular heart disease with atrial fibrillation(AF-VHD)remain unknown when involving long non-coding RNAs(lncRNAs).This study performed system analysis on lncRNA and messenger RNA(mRNA)expression profiles constructed by using bioinformatics methods and tools for biological features of AF-VHD.Fold change and t-test were used to identify differentially expressed(DE)lncRNAs and mRNAs.The enrichment analysis of DE mRNAs was performed.The subgroups formed by lncRNAs and nearby mRNAs were screened,and a transcriptional regulation network among lncRNAs,mRNAs,and transcription factors(TFs)was constructed.The interactions between mRNAs related to lncRNAs and drugs were predicted.The 620 AF-VHDrelated DE lncRNAs and 452 DE mRNAs were identified.The 3 lncRNA subgroups were screened.The 665 regulations mediated by lncRNAs and TFs were identified.The 9 mRNAs related to lncRNAs had 1 or more potential drug interactions,totaling 37 drugs.Of these,9 drugs targeting 3 genes are already known to be able to control or trigger atrial fibrillation(AF)or other cardiac arrhythmias.The found biological features of AF-VHD provide foundations for further biological experiments to better understand the roles of lncRNAs in development from the valvular heart disease(VHD)to AF-VHD.

Atrial fibrillation and rheumatic valvular heart disease:usefulness of very-low-dose amiodarone

Atrial fibrillation （AF） is frequently associated with rheumatic valvular heart disease （RVHD）. AF leads to systemic thromboembolic complications, reduced quality of life （QOL）, impaired ventricular function and also increased mortality. Multivariate analysis of results from a population-based study has shown that valvular heart disease is one of risk factors for development of AF.1 The frequency of RVHD has decreased in developed countries in recent years, but RVHD now constitutes a significant population for the cardiology services in developing countries.

肿瘤坏死因子受体3相互作用蛋白2与心房颤动相关性的临床研究

目的探讨肿瘤坏死因子受体3相互作用蛋白2(TRAF3IP2)与心房颤动(下称房颤)的相关性。方法选择南京医科大学附属淮安第一医院2021年6至12月收治的瓣膜性心脏病患者41例,根据是否合并房颤分为房颤组22例和非房颤组19例。收集患者的临床资料、全血以及部分心房肌组织,比较两组患者TRAF3IP2表达水平和纤维化指标[胶原和α平滑肌肌动蛋白(α-SMA)含量]。结果房颤组左心房直径(LAD)、TRAF3IP2表达水平均高于非房颤组(均P<0.01),TRAF3IP2表达与LAD呈直线相关(r=0.33,P=0.037)。分层分析显示在LAD≤3.5 mm的患者中,房颤组TRAF3IP2表达水平高于非房颤组;在LAD>3.5 mm的患者中,房颤组TRAF3IP2表达水平高于非房颤组(均P<0.01)。马松染色和免疫组化染色显示,房颤组心房肌胶原含量及TRAF3IP2表达水平高于非房颤组。Western blotting结果显示房颤组心房肌组织TRAF3IP2和α-SMA表达水平高于非房颤患者。结论TRAF3IP2与房颤存在相关性,具体表现为房颤患者的TRAF3IP2表达水平高于非房颤患者,提示TRAF3IP2可能参与房颤的进展。

急性阵发性房颤患者基线NT-proBNP对胺碘酮复律疗效的影响

目的 探讨N末端B型利钠肽原(N-terminal pro B-type natriuretic peptide,NT-proBNP)在胺碘酮用于急性阵发性房颤(acute atrial fibrillation,AF)复律疗效评估中的价值。方法纳入2019年2月—2022年7月三明市第二医院急诊科明确诊断为AF(非瓣膜病)的68例患者,所有患者排除禁忌后均给予胺碘酮复律治疗,根据复律后转复情况分为2组,即成功转复组(n=57)与转复失败组(n=11)。对比2组症状与体征(心悸、胸痛)、心电图表现(是否合并ST段压低)、既往病史(是否合并糖尿病、高血压病、冠心病等)、房颤持续时间和基线NT-proBNP水平。采用二元logistic回归分析AF患者胺碘酮复律疗效的影响因素。结果 2组胸痛、合并糖尿病、合并冠心病、ST段压低、房颤持续时间、合并高血压比较,差异无统计学意义(P>0.05)。成功转复组心悸发生率为28.07%、NT-proBNP水平为(229.43±7.24)pmol/L,优于转复失败组的63.64%、(679.99±8.67)pmol/L,差异有统计学意义(P<0.05)。入院时存在心悸症状、NT-proBNP是影响AF患者应用胺碘酮转复的主要因素(P<0.05)。结论 胺碘酮对AF(非瓣膜病)患者复律治疗安全有效,入院时存在心悸症状、基线NT-proBNP水平是预测胺碘酮复律成功的重要因素。

超声心动图联合B型脑钠肽评价非瓣膜性房颤病人卒中风险的研究

目的:探讨生物标志物B型脑钠肽(BNP)水平与左心耳功能预测非瓣膜性心房颤动(NVAF)病人心源性卒中风险的价值及其相关性。方法:选择80例因心房颤动拟接受导管消融或电复律治疗的NVAF病人。收集病人临床及超声心动图资料,包括人口学信息、血BNP水平、术前经胸及经食管超声心动图参数。超声参数包括:左心室舒张末容积(LVEDV)、左心室射血分数(LVEF)、左心房容积指数(LAVI)、心耳排空速度(PEV)。根据有无心耳血栓或左心房红细胞自发显影(SEC)分成卒中风险组和正常组,比较2组参数间的差异,多元logistic回归及受试者特征(ROC)曲线分析各参数与卒中风险的关系,并分析BNP与左心耳功能及LAVI的相关性。结果:80例NVAF病人中,卒中风险组44例(其中心耳血栓9例,左心房SEC 35例),正常组36例。2组年龄、性别、血压、血糖、血脂、血管疾病等方面差异均无统计学意义(P>0.05)。卒中风险组BNP水平、LAVI高于正常组,LVEF、PEV低于正常组,差异均有统计学意义(P<0.01);LVEDV 2组间无明显差异(P>0.05)。多元logistic回归分析显示LAVI、PEV及BNP是卒中风险的独立危险因素(OR=1.270、1.291、1.016,P<0.01)。进一步相关性分析显示,BNP与PEV呈显著负相关(r=-0.549,P<0.01),与LAVI显著正相关(r=0.497,P<0.01)。ROC曲线分析PEV预测心源性卒中风险的最佳截止值26.5cm/s,灵敏度61.4%,特异度97.2%,曲线下面积0.87;LAVI、BNP预测心源性卒中风险ROC曲线下面积分别为0.86、0.78。结论:LAVI、PEV及BNP是NVAF病人卒中风险的独立危险因素,PEV预测卒中风险价值更大,且BNP与PEV、LAVI具有显著相关性,可作为指导临床抗凝治疗有价值的指标。

达比加群酯治疗老年非瓣膜性房颤患者的效果观察

目的探讨达比加群酯治疗老年非瓣膜性房颤患者对凝血功能、心功能的影响及不良反应和预后。方法本研究为随机对照试验,共纳入2020年1月至2023年9月期间天津医科大学第二医院130例老年非瓣膜性房颤患者。通过随机数字表法将患者分为A组(华法林治疗,43例)、B组(利伐沙班治疗,43例)和C组(达比加群酯治疗,44例)。A组男性22例,女性21例,年龄为(74.56±6.43)岁;心功能分级Ⅰ级23例、Ⅱ级20例。B组男性24例,女性19例,年龄为(73.89±6.21)岁;心功能分级Ⅰ级22例、Ⅱ级21例。C组男性20例,女性24例,年龄为(74.12±6.38)岁;心功能分级Ⅰ级23例、Ⅱ级21例。A组接受华法林钠片治疗,每日一次,起始剂量为2.5 mg,后根据国际标准化比值(INR)调整剂量,每次调整0.5mg,保持INR在2.0~3.0之间;B组接受利伐沙班片治疗,每次15mg,每日一次;C组接受达比加群酯胶囊治疗,每次110 mg,每日两次。疗程为2个月。对比3组患者肝肾功能指标[肌酐(Cr)、尿素氮(BUN)、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)]的水平、凝血功能[凝血酶时间(TT)、纤维蛋白原(FIB)、活化部分凝血活酶时间(APTT)、血浆凝血酶原时间(PT)]、心房颤动栓塞风险CHA2DS2-VASc评分、心房颤动抗凝出血风险HAS-BLED评分和不良反应(皮肤瘀斑、恶心呕吐、脑卒中、血尿)的发生情况,并随访3个月,统计3组的血栓栓塞形成率和出血情况。采用重复测量方差分析、χ^(2)检验、Fisher确切概率法。结果治疗2个月后,B组和C组Cr、BUN、ALT和AST水平低于A组,差异均有统计学意义(均P<0.05)。B组和C组TT、APTT、PT高于A组,FIB低于A组,差异均有统计学意义(均P<0.05)。A组、B组和C组CHA2DS2-VASc和HAS-BLED评分较治疗前略升高,但差异均无统计学意义(均P>0.05)。A组、B组和C组的不良反应发生率为16.28%(7/43)、4.65%(2/43)、2.27%(1/44);C组的不良反应发生率低于A组,差异有统计学意义(P<0.05)。随访3个月后,B组和C组的血栓栓塞形成率和轻微出血率略低于A组,但差异均无统计学意义(均P>0.05)。结论相比华法林,达比加群酯和利伐沙班在治疗老年非瓣膜性房颤患者中能改善肝肾功能和凝血功能,降低不良反应发生率,减少血栓栓塞和出血事件,显示出更好的治疗效果和安全性。

二维斑点追踪技术联合实时三维超声心动图对非瓣膜性心房颤动患者左心耳血栓形成的预测价值

目的探讨二维斑点追踪技术(2D-STE)联合实时三维超声心动图(RT-3DE)参数预测非瓣膜性心房颤动(NVAF)患者左心耳血栓(LAAT)形成的价值。方法选取2023年1月至2023年8月于兰州大学第一医院经食管超声检出LAAT的NVAF患者20例为LAAT组,另选取未检出LAAT的NVAF患者52例作为非LAAT组,收集患者二维及三维超声心动图参数及基线资料,比较两组患者之间数据资料的差异;采用logistic回归分析NVAF患者LAAT的影响因素,利用Pearson相关性分析左心房球形度指数(LASI)与左心房容积指数(LAVI)之间的相关性,绘制受试者工作特征(ROC)曲线分析超声心动图参数对NVAF患者血栓的诊断效能。结果与非LAAT组相比,LAAT组患者N末端B型利钠肽原(NT-proBNP)水平升高[1437.50(650.50,2247.50)ng/ml比788.58(158.50,1242.50)ng/ml],差异具有统计学意义(P<0.05);LAAT组左心房前后径、上下径、左右径、LASI、左心房最大容积(LAV)、LAVI高于非LAAT组[(43.15±6.01)mm比(38.24±5.67)mm,(62.68±5.58)mm比(57.77±5.71)mm,(45.72±5.36)mm比(40.43±5.47)mm,(77.30±7.06)%比(69.71±6.24)%,(104.31±28.05)ml比(75.83±23.40)ml,(57.44±15.30)比(41.12±12.40)],左心室射血分数(LVEF)、左心房纵向应变峰值(PALS)低于非LAAT组[(54.16±6.30)%比(59.73±5.10)%,8.75(7.33,12.50)%比15.80(10.73,21.78)%],差异具有统计学意义(P<0.05)。Logistic回归分析显示,LAVI、LASI及PALS与NVAF患者LAAT独立相关。Pearson线性相关性分析显示LASI与LAVI之间正相关(r=0.399,P=0.001)。ROC曲线显示,LASI、LAVI、PALS预测LAAT的曲线下面积(AUC)分别为0.788(95%CI 0.666~0.911,P<0.01)、0.796(95%CI 0.684~0.908,P<0.01)、0.808(95%CI 0.698~0.919,P<0.01),最佳截断值分别为76.10%、53.92 ml/m^(2)、9.85%。联合预测LAAT时AUC为0.861(95%CI 0.761~0.960,P<0.05),特异度为85.0%,敏感度为75.0%。结论LAVI、LASI及PALS是NVAF患者LAAT的独立预测因子。2D-STE结合RT-3DE可以可作为一种经济、便捷、无创的工具,联合预测更有助于NVAF患者LAAT的检测。

非瓣膜性心房颤动患者服用新型口服抗凝药发生消化道出血的危险因素分析

目的探讨非瓣膜性心房颤动患者服用新型口服抗凝药发生消化道出血的危险因素。方法选取2016年1月至2023年5月在首都医科大学附属北京安贞医院住院的因非瓣膜性心房颤动服用新型口服抗凝药的患者,纳入在住院期间发生消化道出血的患者作为出血组,根据年龄、性别及新型口服抗凝药的类型和剂量进行1∶2随机匹配,纳入在住院期间未发生消化道出血的患者作为未出血组。收集2组患者一般资料、合并症、药物使用、化验指标等信息。采用Logistic回归分析探讨非瓣膜性心房颤动患者服用新型口服抗凝药发生消化道出血的危险因素,绘制受试者工作特征(ROC)曲线并计算曲线下面积(AUC)以评估危险因素对非瓣膜性心房颤动患者服用新型口服抗凝药发生消化道出血的预测价值。结果共纳入服用新型口服抗凝药的患者153例,其中出血组患者51例,未出血组患者102例。出血组患者合并冠心病(冠状动脉粥样硬化性心脏病)、心功能不全、既往消化道出血史、消化性溃疡、贫血、慢性肾功能不全、静脉血栓栓塞症、周围血管病比例均高于未出血组(均P<0.05)。出血组患者的基线血红蛋白水平低于未出血组,中性粒细胞百分比、血尿素氮、D-二聚体水平高于未出血组(均P<0.05)。多因素Logistic回归分析结果显示,冠心病(比值比=4.678,95%置信区间:1.600~13.677)、既往消化道出血史(比值比=9.906,95%置信区间:1.449~67.742)、慢性肾功能不全(比值比=4.893,95%置信区间:1.122~21.330)、贫血(比值比=13.487,95%置信区间:1.847~98.496)、D-二聚体(比值比=1.001,95%置信区间:1.000~1.003)是新型口服抗凝药治疗非瓣膜性心房颤动时发生消化道出血的独立危险因素。联合上述指标绘制ROC曲线,曲线下面积(AUC)为0.905(95%置信区间:0.854~0.955,P<0.001)。结论冠心病、既往消化道出血史、慢性肾功能不全、贫血、D-二聚体是非瓣膜性心房颤动患者服用新型口服抗凝药发生消化道出血的独立危险因素。

专科医护远程照护非瓣膜性心房颤动病人介入术后护理评估指标的构建

目的:构建专科医护远程照护非瓣膜性心房颤动病人介入术后护理评估指标体系,旨在为我国远程照护提供参考。方法:通过文献回顾和分析,整合非瓣膜性心房颤动病人介入术后常见护理问题,以奥马哈问题分类系统为依据,将相关护理问题整理、分类,最后采用德尔菲专家函询法对纳入指标进行连续2轮专家函询,构建专科医护远程照护非瓣膜性心房颤动病人介入术后护理评估指标体系。结果:2轮函询问卷的回收率均为100%,2轮函询专家的权威系数分别为0.881和0.910,肯德尔协调系数分别为0.711和0.821(P<0.05)。最终构建的专科医护远程照护非瓣膜性心房颤动病人介入术后护理评估指标体系包括5个一级指标、16个二级指标、62个三级指标,各条目变异系数均<0.25。结论:构建的专科医护远程照护非瓣膜性心房颤动病人介入术后护理评估指标体系科学、可靠,既保证了临床实施的可行性,又可为我国专科医护远程照护提供参考。

非瓣膜性心房颤动左心耳血栓的影像学研究进展

非瓣膜性心房颤动因其高发病率、高致残率和高复发率,严重影响了患者的生活质量。准确评估左心耳的结构和功能,对检测左心耳血栓和预测卒中事件至关重要。以经食管超声心动图、经胸超声心动图、心腔内超声心动图、CT和心脏磁共振成像等为主的传统影像学技术,和以新型分子靶向示踪剂结合的正电子发射断层扫描/心脏磁共振成像、计算机流体力学等为代表的新兴技术,正为左心耳的结构功能评估以及左心耳血栓的检测提供着重要客观依据。本文对非瓣膜性心房颤动患者左心耳的解剖、功能、左心耳及其血栓的影像学研究进展进行综述。

利伐沙班致非瓣膜性心房颤动合并冠心病患者相关出血事件的影响因素分析

目的分析利伐沙班致非瓣膜性心房颤动(NVAF)合并冠心病患者相关出血事件的影响因素。方法回顾性收集福州大学附属省立医院心血管内科2021年11月-2023年5月使用利伐沙班进行抗凝治疗的NVAF合并冠心病住院患者64例,分析其人口统计学信息、实验室检查指标等一般临床资料及利伐沙班稳态血药浓度谷值,计算剂量调整谷浓度,并记录患者出院后6个月内相关出血事件的发生情况。采用单因素分析和二元Logistic回归分析确定利伐沙班相关出血事件的独立危险因素。构建预测出血概率的二元Logistic回归方程,采用受试者操作特征(ROC)曲线的曲线下面积(AUC)分析该回归方程的预测价值。结果64例患者中,共19例患者发生24例次出血事件,大多为轻度出血(19例次,79.2%),以胃肠道出血为主(17例次,70.8%),大多经对症处理、调整抗凝方案等处理后好转或痊愈。单因素分析结果显示,出血组既往有贫血史的患者比例、血小板计数、尿素氮含量、利伐沙班稳态血药浓度谷值、利伐沙班剂量调整谷浓度和凝血指标[国际标准化比值、凝血酶原时间(PT)、活化部分凝血活酶时间]水平均显著多于或高于非出血组,而白蛋白水平显著低于非出血组(P<0.05)。二元Logistics回归分析结果显示,高PT水平(比值比为1.473,95%置信区间为1.103~1.967,P=0.009)和高利伐沙班剂量调整谷浓度(比值比为1.174,95%置信区间为1.018~1.355,P=0.027)是利伐沙班相关出血事件的独立危险因素;出血事件预测概率(P)的二元Logistic回归方程为Logit P=-6.975+0.387×PT水平+0.161×剂量调整谷浓度,其ROC曲线的AUC为0.825(95%置信区间为0.708~0.909,P<0.001)。结论利伐沙班致NVAF合并冠心病患者相关出血事件的危险因素包括既往有贫血史、高血小板计数、高尿素氮含量、高利伐沙班稳态血药浓度谷值、高剂量调整谷浓度、高凝血指标水平以及低白蛋白水平,其中高PT水平和高剂量调整谷浓度是可用于预测利伐沙班相关出血事件发生风险的独立危险因素;所建回归方程具有较高的预测价值。

基于蒙特卡罗模拟优化不同肾功能分级患者的利伐沙班抗凝方案

目的优化不同肾功能分级患者的利伐沙班抗凝给药方案。方法根据利伐沙班药品说明书及患者实际服药情况设定给药方案,根据河北省人民医院患者利伐沙班谷浓度参考范围及国际血液学标准化委员会推荐的利伐沙班实验室监测浓度参考范围,设置目标浓度范围区间及分段区间,采用OracleCrystalBall软件(V11.1.2.4),通过蒙特卡罗模拟考察不同给药方案的利伐沙班稳态谷浓度落在各目标浓度范围区间的中靶概率。结果共纳入非瓣膜性房颤患者97例,其检测利伐沙班稳态谷浓度125次、中位稳态谷浓度为32.2 ng/mL;共纳入静脉血栓患者121例,其检测利伐沙班稳态谷浓度159次、中位稳态谷浓度为31.0 ng/mL。非瓣膜性房颤患者的稳态谷浓度参考范围为12~137、3~153 ng/mL,静脉血栓患者的稳态谷浓度参考范围为6~239、3~224 ng/mL。蒙特卡罗模拟结果显示,对于非瓣膜性房颤患者,当肾小球滤过率(eGFR)为0~30mL/min时,其利伐沙班最佳给药方案为每次5mg,每天1次;当eGFR为>30~60mL/min时,其利伐沙班最佳给药方案为每次10~20mg,每天1次或每次5mg,每天2次;当eGFR为>60~90 mL/min时,其利伐沙班最佳给药方案为每次15~30 mg,每天1次或每次5~10 mg,每天2次;当eGFR为>90~120 mL/min时,其利伐沙班最佳给药方案为每次25~30 mg,每天1次或每次5~15 mg,每天2次。对于静脉血栓患者,当eGFR为0~30mL/min时,不推荐每天使用利伐沙班超过5mg;当eGFR为>30~60mL/min时,其利伐沙班最佳给药方案为每次5mg,每天1次;当eGFR为>60~90mL/min时,其利伐沙班最佳给药方案为每次25~30mg,每天1次或每次5~15mg,每天2次;当eGFR为>90~120 mL/min时,其利伐沙班最佳给药方案为每次10~15 mg,每天2次。结论临床对肾功能严重损伤的患者应谨慎选择利伐沙班抗凝。利伐沙班谷浓度参考范围宽泛、个体差异性大,可通过蒙特卡罗模拟方法,结合患者肾功能,个体化选择利伐沙班服药剂量和频次。

频发室性早搏与心脏瓣膜手术同期迷宫手术后心房颤动复发关系研究

目的:探讨频发室性早搏(VPB)与心脏瓣膜手术同期射频消融迷宫手术(CMA)后心房颤动(AF)复发的关系。方法:收集因瓣膜疾病合并AF行心脏瓣膜手术同期射频消融迷宫手术的患者115例进行单中心、回顾性、病例对照研究,按照AF是否复发进行分组,复发AF患者23例,未复发患者92例。收集患者一般临床资料和相关实验室检查并评估术前室性早搏负荷(室性早搏数量>10000个/24 h为频发室性早搏)。采用单因素和多因素Cox比例风险回归模型对合并瓣膜疾病的AF患者在接受心脏瓣膜手术及同期射频消融迷宫手术后AF复发的危险因素进行分析。结果:与未复发组比较,复发组室性早搏负荷较高(P<0.05)。多因素Cox回归分析结果显示,频发室性早搏和糖尿病是进行心脏瓣膜手术并同期接受射频消融迷宫手术的患者AF复发的独立危险因素(均P<0.05)。结论:频发室性早搏是心脏瓣膜手术同期射频消融迷宫手术后心房颤动复发的危险因素。

县级医院非瓣膜性心房颤动住院患者抗凝治疗影响因素分析

目的:探讨县级医院非瓣膜性心房颤动(NVAF)住院患者抗凝治疗影响因素。方法:回顾性分析广德市人民医院收治的416例NAVF患者的临床资料,根据是否应用口服抗凝药分为抗凝组214例和未抗凝组202例,新型口服抗凝药物(NOAC)治疗的170例患者根据剂量是否符合欧洲心律协会指南推荐,分为标准剂量组25例与非标准剂量组145例,经单因素和多因素logistic回归分析,筛选出抗凝治疗及NOAC剂量的影响因素。结果:416例NVAF患者中男性245例,平均年龄(76.3±7.6)岁,CHA2DS2-VASc评分为(4.3±1.6)分,HAS-BLED评分为(1.9±0.9)分。多因素logistic回归分析显示,与未抗凝组相比,抗凝组NVAF患者卒中风险高危、收住心内科、合用β受体阻滞剂和肾素-血管紧张素系统(RAS)抑制剂的比例更高(OR=2.87、1.01、1.83、1.80、3.27,P均<0.05)。与标准剂量组相比,非标准剂量组患者年龄≥75岁、肾小球滤过率降低的比例更高(OR=0.08、0.97、P均<0.05)。结论:县级医院NVAF患者的抗凝治疗明显不足,卒中风险高危、收住心内科、合并应用β受体阻滞剂和RAS抑制剂是提高抗凝治疗率的有利因素。年龄大于75岁、肾功能减低是使用NOAC非标准剂量的独立影响因素。