住院房颤患者华法林应用现况的回顾性分析

  本文关键词：住院房颤患者华法林应用现况的回顾性分析，，由笔耕文化传播整理发布。

住院房颤患者华法林应用现况的回顾性分析

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摘要

目的：
     1.统计并描述房颤患者临床特征及华法林应用概况；
     2.分析探讨非瓣膜性房颤(Non-Valvular Atrial Fibrillation, NVAF)患者卒中风险分层和出血风险分层特点及各分层中华法林的实际应用情况,调查评价其用药过程中抗凝强度监测情况；
     3.探索并分析影响临床医师应用华法林的可能因素。
     研究方法：
     1.采用回顾性研究方法,收集2011年1月-2012年12月在齐鲁医院住院治疗的房颤患者的临床资料,统计并描述其临床特征。
     2.对NVAF患者分别应用CHADS2评分(Congestive heart failure, Hypertension, Age≥75years, Diabetes mellitus, Stroke; CHADS2Score)及CHA2DS2-VASc评分(Congestive heart failure, Hypertension, Age≥75years, Diabetes mellitus, Stroke,Vascular disease, Age65-74years, Sex category; CHA2DS2-VASc Score)进行卒中风险分层,比较CHADS2评分和CHA2DS2-VASc评分对卒中风险评估的差异；应用HAS-BLED评分(Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly; HAS-BLED Score)进行出血风险评估；分析探讨各分层抗凝药物应用情况。
     3.调查NVAF患者应用华法林抗凝治疗时,抗凝强度(INR)的监测情况。
     4.对可能影响NVAF患者抗凝用药决策的因素进行单因素分析及多因素回归分析,并依据回归分析的结果进一步分析特殊人群抗凝药物用药情况。
     结果：
     1.本研究共纳入968例房颤患者,其中NVAF患者784例、瓣膜性房颤患者184例。根据CHADS2评分标准,NVAF患者中卒中风险高危、中危、低危的房颤患者分别占总数58.3%(457/784)、26.1%(205/784)、15.6%(122/784)。根据CHA2DS2-VASc评分标准,NVAF患者中卒中风险高危、中危、低危的房颤患者分别占总数82.3%(645/784)、11.7%(92/784)、6.0%(47/784)。
     2.住院房颤患者华法林总用药率为26.5%(256/968),NVAF患者及瓣膜性房颤患者华法林用药率分别为18.5%(145/784)和60.3%(111/184)(P＜0.001)。依据CHADS2评分标准,NVAF患者中卒中风险高危、中危、低危患者华法林用药率依次为：16.9%(77/457)、16.1%(33/205)、28.7%(35/122)。依据CHA2DS2-VASc评分标准,NVAF患者中卒中风险高危、中危、低危患者华法林用药率依次为：16.0%(103/645)、22.8%(21/92)、44.7%(21/47)。随着卒中风险评分及出血评分增高,华法林用药率降低。根据2012中国专家共识,高危患者推荐应用华法林,而实际应用华法林比例仅为16.9%(77/457)。根据2012更新版欧洲房颤指南,推荐使用华法林抗凝治疗者中的华法林实际应用率为16.48%(117/710)。
     3.145例应用华法林的NVAF患者中,有134例国际标准化比值(International Normalized Ratio, INR)资料完整,其中20.2%(27/134)INR处于2.0-3.0之间,36.6%(49/134)INR处于1.5-2.5之间。INR的平均值为1.69±0.84。
     4.单因素分析结果显示,高龄(≥65岁)、合并冠心病(Coronary Artery Disease, CAD)、合并心衰、合并出血史、心内科住院的NVAF患者的华法林用药率与未合并相应因素者相比有明显差异。Logistic回归分析结果显示,高龄(≥65岁)、合并CAD和住院科室三项因素对NVAF患者华法林用药决策影响较大。大于等于65岁的老年NVAF患者华法林用药率明显低于小于65岁的中青年NVAF患者(分别为12.1%和33.6%,,P＜0.001)。合并CAD的NVAF患者中,应用阿司匹林联合氯吡格雷者占20.7%(91/440),华法林用药率为12.3%(54/440),低于未合并CAD的NVAF患者(26.5%,91/344)(P＜0.05)。心内科住院NVAF患者华法林用药率为(100/398),明显高于其他科室住院NVAF患者的华法林用药率(分别为25.1%和11.7%,P＜0.001)。
     结论：
     1.与CHADS2评分标准相比,CHA2DS2-VASc评分标准划分的卒中风险中危、低危患者比例较低,而高危患者比例较高。
     2.根据欧洲指南和中国专家共识,本中心住院房颤患者华法林用药率还远未达到标准。卒中高危患者华法林用药率较低,而卒中风险低危患者存在华法林过度使用的问题。
     3.本研究中使用华法林的NVAF患者INR偏低,大多数未达到INR目标范围(INR：2.0-3.0),抗凝强度远远不够,未能起到有效预防脑卒中的效果。
     4.华法林在老年NVAF患者、合并冠心病的NVAF患者以及非心内科住院的NVAF患者中应用率较低。临床医师应重视老年NVAF患者以及合并冠心病的NVAF患者中华法林的合理应用,非心内专业临床医师更应加强房颤抗凝的意识。
Objective:(1)To study the clinical character and warfarin usage in patients with Atrial fibrillation(AF).(2) To evaluate the stroke and bleeding risk of non-valvular atrial fibrillation (NVAF) patients with current standard risk stratification models and to analysis the current status of anticoagulation therapy for NVAF patients.(3)To explore the possible factors that affect the decisions of warfarin treatment.
     Methods:A retrospective, observational study was carried out. Inpatients diagnosed with atrial fibrillation in Qilu hospital institution between2011.1and2012.12were included. Patients with NVAF were categoried by stroke risk (CHADS2Score and CHA2DS2-VASc Score) and bleeding risk (HAS-BLED Score). Standard statistical methods were uesd to analysis the antithrombotic treatment in different risk categories. The international normalized ratio (INR) was investigated among the NVAF patients who used warfarin. Logistic regression analysis were used to explore the possible factors influencing the treatment decisions.
     Results:
     1. Of the968AF patients included in our study,184patients were dignosed with valvular atrial fibrillation, and784patients were dignosed with NVAF. According to CHADS2score,58.3%(457/784) of NVAF patients were defined as high risk (score>2),26.1%(205/784) as intermediate risk (score=1), and15.6%(122/784) as low risk(score=0). According to the CHA2DS2-VASc score,82.3%(645/784) of NVAF patients were defined as high risk (score≥2),11.7%(92/784) as intermediate risk (score=1), and6.0%(47/784) as low risk(score=0).
     2. Among968AF patients,26.5%(256/968) patient were prescribed with warfarin. 60.3%(111/184) of NVAF patients and18.5%(145/784) of valvular AF patients were treated with warfarin(p<0.001). According to CHADS2score,16.9%(77/457) of high-risk patients,16.1%(33/205) of intermediate-risk patients and28.7%(35/122) of low-risk patients were treated with warfarin. According to CHA2DS2-VASc score, the application warfarin in patients of high, intermediate, low risk were16.0%(103/645),22.8%(21/92),44.7%(21/47) respectively. For high stroke-risk patients who are recommended by Chinese experts' consensus to use warfarin, the medication rate was only16.9%(77/457). According to2012updated ESC Guidelines for the management of atrial fibrillation, only16.5%(117/710) of warfarin-recommended patients were treated with warfarin.
     3. Among145NVAF patients taking warfarin,134patients' INR were measured.20%of NVAF patients met the target INR levels(2.0-3.0) and37%(49/134)of NVAF patients' INR levels were within the range of1.5to2.5. Average INR value of134patients was1.69±0.84.
     4. Univariate analysis showed that age(≥65years), inpatients'department, heart failure, bleeding and coronary heart disease affect usage of warfarin. Logistic regression showed that age(≥65years), inpatient department, and coronary heart disease were more closely related to the usage of warfarin. Warfarin was given to33.6%of the young AF patients(<65years), while only12.1%of elderly patients (≥65years) used warfarin (p<0.001). Warfarin was given to25.1%of NVAF patients hospitalized in the cardiological department, while11.7%of NVAF patients hospitalized in other departments used warfarin (p<0.001). Among440NVAF patients with coronary artery disease (CAD),20.7%were treated with dual antiplatelet therapy(aspirin and clopidogrel);12.3%of patients were treated with warfarin. While the warfarin usage rate in NVAF patients without CAD was26.5%.
     Conclusion:
     1. Compared with the CHADS2score, the CHA2DS2-VASc score classifies less patients into low and mediate stroke risk, and more patients into high-risk category.
     2. According to the ESC Guidelines and Chinese experts' consensus, The rate of warfarin usage do not meet the requirements and the usage of warfarin was irrational.
     3. Among patients treated with warfarin, less than1/5meet the target INR levels(2.0-3.0), which indicates that anticoagulation intensity did not measure up to the standard.
     4. Warfarin usage rate in the elderly NVAF patients and NVAF patients with CAD is relatively low. Clinician should pay more attention to the rational usage of warfarin in elderly NVAF patients and NVAF patients with CAD.

引文

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  本文关键词：住院房颤患者华法林应用现况的回顾性分析，由笔耕文化传播整理发布。