单中心心房颤动病人流行病学特点和抗凝治疗现状分析

发布时间：2018-07-02 07:58

本文选题：心房颤动 + 口服抗凝剂　；参考：《山东大学》2017年硕士论文

【摘要】：[目的]在一组单中心"真实世界"的心房颤动(房颤)病人中前瞻性分析房颤人群的流行病学特点以及抗凝治疗现状。[方法]自2016.3至2016.9前瞻性纳入在山东大学齐鲁医院青岛院区就诊的房颤病人509例,观察性分析病人的流行病学特点、抗栓/抗凝治疗率、栓塞风险评估、随访6个月时的栓塞事件及出血事件的发生率,分析影响抗凝治疗率的主要因素,并探索提高高栓塞风险的房颤病人抗凝治疗率的措施。[结果]共462例房颤病人(平均年龄71.2± 12.7岁)完成了该观察性研究,其中男性274例(59.3%)、女性例188(40.7%)。常见的伴随疾病有高血压(78.4%)、糖尿病(24.9%)、冠心病(20.8%)和心力衰竭(13.4%)。共有126例(27.3t%)未行抗栓治疗,174例(37.7,%)抗血小板药物治疗,162例(35.0%)行抗凝药物治疗,其中101例(62.3%)服用华法林,51例(37.7,%)服用新型口服抗凝剂(N0AC)达比加群酯。在30例瓣膜性房颤病人中24例行华法林抗凝治疗,治疗率为80%,另外4例抗血小板治疗,2例未行抗栓治疗。在432例非瓣膜性房颤病人中,CHADS2评分为2.1±1.4,CHA2DS2-VASc评分为4.2±1.9。全部病人的HAS-BLED)评分为2.5±1.4。在126例未行抗栓治疗的房颤病人中,主要原因包括:服用华法林检测INR值繁琐(37%)、担心出血风险(29%)、NOACs费用高(21%)、不了解抗凝治疗目的(13%)等。在HAS-BLED)评分≥5分的病人中,抗凝治疗率为0%,而抗血小板治疗率为100%。经过6个月的随访,共有38例发生了血栓栓塞事件,均为非瓣膜性房颤病人,总体栓塞事件发生率为8.2%,其中未治疗组15例(11.9%),抗血小板治疗组16例(9.2%),抗凝治疗组7例(4.3%)(P0.05)。影响栓塞事件结局的危险因素包括:左心房直径、既往栓塞病史、年龄和外周动脉疾病。多因素分析显示,既往栓塞史可显著增加栓塞风险。与未抗栓治疗组相比,抗血小板治疗组的血栓栓塞事件相对危险下降22.7%,但未达统计学差异(P=0.283,OR=0.749,95%CI0.356-1.579),而抗凝治疗组的血栓栓塞事件发生率显著降低,相对危险度下降63.9%(P=0.015,0R=0.334,95%CI 0.132-0.847)。抗血小板治疗组和抗凝治疗组的栓塞事件发生率虽然未达到统计学差异,但抗凝治疗组比抗血小板治疗组的相对危险度减少53.3%(P=0.059,0R=0.446,95%CI 为 0.179-1.114)。栓塞事件发生率随 CHADS2、CHA2DS2-VASc评分的增加而增加,栓塞组与未栓塞组的CHADS2评分分别为3.05±1.49 比 2.06±1.38(P0.001),CHA2DS2-VASc 评分分别为 5.53±1.72 比4.11±1.82(/0.001)。在未抗栓治疗组,CHADS2=0的病人其栓塞事件发生率高达13.0%,而在CHA2DS2-VASc=0或1的病人,其栓塞事件发生率为0。采用Roc曲线计算C-statistic值的结果表明,CHA2DS2-VASc评分(0.717,CI 0.635-0.798,P0.001)比 CHADS2 评分(0.698,CI0.608-0.707,P0.001)具有更高的栓塞风险预测价值。共发生5例大出血事件,其中瓣膜性房颤病人1例,非瓣膜性房颤病人4例;抗凝治疗组3例,抗血小板治疗组1例。[结论]房颤好发于老年人,男性多于女性,抗凝治疗率总体偏低,且随着CHA2DS2-VASc评分的增加逐渐降低,而抗血小板治疗率逐渐增加。未行抗凝治疗主要原因包括服用华法林检测INR值繁琐、担心出血风险、NOACs费用昂贵、不了解抗凝治疗目的等。抗血小板治疗未显著降低栓塞事件发生率,而抗凝治疗可显著降低栓塞事件的发生率。CHA2DS2-VASc评分系统具有比CHADS2评分系统更高的栓塞风险预测敏感性。提高医生对房颤管理指南的依从性、将NOACs药物纳入医保目录、加强对房颤病人的健康宣教和是提高高栓塞风险的房颤病人抗凝治疗率、降低栓塞事件发生率的重要措施。
[Abstract]:[Objective] to prospectively analyze the epidemiological characteristics of atrial fibrillation and the status of anticoagulant therapy in a group of patients with single center "real world" atrial fibrillation (atrial fibrillation). [Methods] 509 cases of atrial fibrillation in Qingdao Hospital of Qilu Hospital of Shandong University were prospectively included in 509 cases. The epidemiological characteristics of the patients were analyzed by observational analysis. Embolic / anticoagulant therapy rate, embolization risk assessment, the incidence of embolism events and bleeding events at 6 months of follow-up, analysis of the main factors affecting the rate of anticoagulant therapy, and the exploration of measures to improve the anticoagulant rate of atrial fibrillation patients with high risk of embolism. [results] 462 patients with atrial fibrillation (average age 71.2 + 12.7 years old) completed the observational study, In 274 cases (59.3%) and 188 (40.7%) for women, common associated diseases were hypertension (78.4%), diabetes (24.9%), coronary heart disease (20.8%) and heart failure (13.4%). There were 126 cases (27.3t%) without antithrombotic therapy, 174 (37.7,%) antithrombotic therapy, 162 (35%) treated with anticoagulant, among them, warfarin was taken. In 30 patients with valvular atrial fibrillation, 24 of 30 patients with valvular atrial fibrillation were treated with warfarin anticoagulant therapy, the treatment rate was 80%, 4 were antiplatelet therapy and 2 had no antithrombotic therapy. In 432 patients with non valvular atrial fibrillation, the CHADS2 score was 2.1 + 1.4 and the CHA2DS2-VASc score was 4.2 + 1.9. in all patients with HAS-BLED. The main reasons were 2.5 + 1.4. in 126 cases of atrial fibrillation patients without antithrombotic treatment. The main reasons were: the Hua Falin test was tedious (37%), the risk of bleeding (29%), the high cost of NOACs (21%), the anticoagulant treatment (13%). The anticoagulant rate was 0% in the patients with the score of 5 in HAS-BLED, and the antiplatelet therapy rate was 100%. 6. A total of 38 patients were followed up with thromboembolic events, all of which were non valvular atrial fibrillation, with a total incidence of 8.2%, including 15 in the untreated group (11.9%), 16 in the antiplatelet therapy group (9.2%) and 7 in the anticoagulant group (4.3%) (P0.05). The risk factors affecting the outcome of the embolus event included the left atrial diameter, the history of previous embolism. Age and peripheral arterial disease. Multivariate analysis showed that previous embolic Shi Ke significantly increased the risk of embolism. Compared with the non antithrombotic treatment group, the relative risk of thromboembolism in the antithrombotic therapy group decreased by 22.7%, but was not statistically significant (P=0.283, OR=0.749,95%CI0.356-1.579), while the incidence of thromboembolism events in the anticoagulant treatment group was significant. The relative risk decreased by 63.9% (P=0.015,0R=0.334,95%CI 0.132-0.847). The incidence of thromboembolism events in the antiplatelet therapy group and the anticoagulant treatment group was not statistically significant, but the relative risk of the anticoagulant therapy group decreased by 53.3% (P= 0.059,0R=0.446,95%CI 0.179-1.114). The rate increased with the increase of CHADS2 and CHA2DS2-VASc scores. The CHADS2 score of the embolization group and the non embolic group was 3.05 + 1.49 to 2.06 + 1.38 (P0.001), and the CHA2DS2-VASc score was 5.53 + 1.72 to 4.11 + 1.82 (/0.001). In the non antithrombotic treatment group, the incidence of Embolism Events was up to 13% in the patients with CHADS2=0 and in CHA2DS2-VASc=0 or 1. Patients, the incidence of their embolic events was 0. using the Roc curve to calculate the C-statistic value. The CHA2DS2-VASc score (0.717, CI 0.635-0.798, P0.001) had a higher predictive value than the CHADS2 score (0.698, CI0.608-0.707, P0.001). There were 5 cases of massive hemorrhage, including 1 patients with valvular atrial fibrillation and non valvular atrial fibrillation. There were 4 cases of patients, 3 cases in anticoagulant treatment group and 1 cases in antiplatelet therapy group. [Conclusion] atrial fibrillation is better in the elderly, more men than women, and the rate of anticoagulant treatment is generally low, and with the increase of CHA2DS2-VASc score, the rate of antiplatelet therapy is gradually increased. The main reason for non anticoagulant treatment includes the fussy INR value of warfarin test. The risk of bleeding, NOACs is expensive and does not understand the purpose of anticoagulant therapy. Antiplatelet therapy does not significantly reduce the incidence of embolic events, and anticoagulant therapy can significantly reduce the incidence of embolic events in the.CHA2DS2-VASc scoring system with higher risk pretest sensitivity than the CHADS2 scoring system. In terms of sex, NOACs drugs are included in the medical insurance catalogue, strengthening health education for patients with atrial fibrillation and improving the rate of anticoagulant therapy for patients with high risk of embolism and reducing the incidence of embolic events.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.75

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