本文關(guān)鍵詞：住院房顫患者華法林應(yīng)用現(xiàn)況的回顧性分析，，由筆耕文化傳播整理發(fā)布。

住院房顫患者華法林應(yīng)用現(xiàn)況的回顧性分析

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摘要

目的：
     1.統(tǒng)計并描述房顫患者臨床特征及華法林應(yīng)用概況；
     2.分析探討非瓣膜性房顫(Non-Valvular Atrial Fibrillation, NVAF)患者卒中風(fēng)險分層和出血風(fēng)險分層特點及各分層中華法林的實際應(yīng)用情況,調(diào)查評價其用藥過程中抗凝強度監(jiān)測情況；
     3.探索并分析影響臨床醫(yī)師應(yīng)用華法林的可能因素。
     研究方法：
     1.采用回顧性研究方法,收集2011年1月-2012年12月在齊魯醫(yī)院住院治療的房顫患者的臨床資料,統(tǒng)計并描述其臨床特征。
     2.對NVAF患者分別應(yīng)用CHADS2評分(Congestive heart failure, Hypertension, Age≥75years, Diabetes mellitus, Stroke; CHADS2Score)及CHA2DS2-VASc評分(Congestive heart failure, Hypertension, Age≥75years, Diabetes mellitus, Stroke,Vascular disease, Age65-74years, Sex category; CHA2DS2-VASc Score)進(jìn)行卒中風(fēng)險分層,比較CHADS2評分和CHA2DS2-VASc評分對卒中風(fēng)險評估的差異；應(yīng)用HAS-BLED評分(Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly; HAS-BLED Score)進(jìn)行出血風(fēng)險評估；分析探討各分層抗凝藥物應(yīng)用情況。
     3.調(diào)查NVAF患者應(yīng)用華法林抗凝治療時,抗凝強度(INR)的監(jiān)測情況。
     4.對可能影響NVAF患者抗凝用藥決策的因素進(jìn)行單因素分析及多因素回歸分析,并依據(jù)回歸分析的結(jié)果進(jìn)一步分析特殊人群抗凝藥物用藥情況。
     結(jié)果：
     1.本研究共納入968例房顫患者,其中NVAF患者784例、瓣膜性房顫患者184例。根據(jù)CHADS2評分標(biāo)準(zhǔn),NVAF患者中卒中風(fēng)險高危、中危、低危的房顫患者分別占總數(shù)58.3%(457/784)、26.1%(205/784)、15.6%(122/784)。根據(jù)CHA2DS2-VASc評分標(biāo)準(zhǔn),NVAF患者中卒中風(fēng)險高危、中危、低危的房顫患者分別占總數(shù)82.3%(645/784)、11.7%(92/784)、6.0%(47/784)。
     2.住院房顫患者華法林總用藥率為26.5%(256/968),NVAF患者及瓣膜性房顫患者華法林用藥率分別為18.5%(145/784)和60.3%(111/184)(P＜0.001)。依據(jù)CHADS2評分標(biāo)準(zhǔn),NVAF患者中卒中風(fēng)險高危、中危、低�；颊呷A法林用藥率依次為：16.9%(77/457)、16.1%(33/205)、28.7%(35/122)。依據(jù)CHA2DS2-VASc評分標(biāo)準(zhǔn),NVAF患者中卒中風(fēng)險高危、中危、低�；颊呷A法林用藥率依次為：16.0%(103/645)、22.8%(21/92)、44.7%(21/47)。隨著卒中風(fēng)險評分及出血評分增高,華法林用藥率降低。根據(jù)2012中國專家共識,高�；颊咄扑]應(yīng)用華法林,而實際應(yīng)用華法林比例僅為16.9%(77/457)。根據(jù)2012更新版歐洲房顫指南,推薦使用華法林抗凝治療者中的華法林實際應(yīng)用率為16.48%(117/710)。
     3.145例應(yīng)用華法林的NVAF患者中,有134例國際標(biāo)準(zhǔn)化比值(International Normalized Ratio, INR)資料完整,其中20.2%(27/134)INR處于2.0-3.0之間,36.6%(49/134)INR處于1.5-2.5之間。INR的平均值為1.69±0.84。
     4.單因素分析結(jié)果顯示,高齡(≥65歲)、合并冠心病(Coronary Artery Disease, CAD)、合并心衰、合并出血史、心內(nèi)科住院的NVAF患者的華法林用藥率與未合并相應(yīng)因素者相比有明顯差異。Logistic回歸分析結(jié)果顯示,高齡(≥65歲)、合并CAD和住院科室三項因素對NVAF患者華法林用藥決策影響較大。大于等于65歲的老年NVAF患者華法林用藥率明顯低于小于65歲的中青年NVAF患者(分別為12.1%和33.6%,,P＜0.001)。合并CAD的NVAF患者中,應(yīng)用阿司匹林聯(lián)合氯吡格雷者占20.7%(91/440),華法林用藥率為12.3%(54/440),低于未合并CAD的NVAF患者(26.5%,91/344)(P＜0.05)。心內(nèi)科住院NVAF患者華法林用藥率為(100/398),明顯高于其他科室住院NVAF患者的華法林用藥率(分別為25.1%和11.7%,P＜0.001)。
     結(jié)論：
     1.與CHADS2評分標(biāo)準(zhǔn)相比,CHA2DS2-VASc評分標(biāo)準(zhǔn)劃分的卒中風(fēng)險中危、低�；颊弑壤�較低,而高�；颊弑壤�較高。
     2.根據(jù)歐洲指南和中國專家共識,本中心住院房顫患者華法林用藥率還遠(yuǎn)未達(dá)到標(biāo)準(zhǔn)。卒中高�；颊呷A法林用藥率較低,而卒中風(fēng)險低�；颊叽嬖谌A法林過度使用的問題。
     3.本研究中使用華法林的NVAF患者INR偏低,大多數(shù)未達(dá)到INR目標(biāo)范圍(INR：2.0-3.0),抗凝強度遠(yuǎn)遠(yuǎn)不夠,未能起到有效預(yù)防腦卒中的效果。
     4.華法林在老年NVAF患者、合并冠心病的NVAF患者以及非心內(nèi)科住院的NVAF患者中應(yīng)用率較低。臨床醫(yī)師應(yīng)重視老年NVAF患者以及合并冠心病的NVAF患者中華法林的合理應(yīng)用,非心內(nèi)專業(yè)臨床醫(yī)師更應(yīng)加強房顫抗凝的意識。
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.

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  本文關(guān)鍵詞：住院房顫患者華法林應(yīng)用現(xiàn)況的回顧性分析，由筆耕文化傳播整理發(fā)布。