老年心房颤动患者合并急性冠脉综合征支架治疗后抗栓治疗的长期效果和出血危险因素
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摘要
目的探讨老年心房颤动(AF)合并急性冠脉综合征(ACS)患者不同抗栓治疗的长期安全性和有效性,并分析影响出血的危险因素。方法采用回顾性队列研究方法连续选取2014年1月-2016年12月在首都医科大学附属某医院诊治的≥60岁老年AF合并ACS患者389例,根据抗栓方案将患者分为2组,华法林+阿司匹林+氯吡格雷三联抗栓组简称TT组112例和华法林+氯吡格雷二联抗栓组简称WC组277例。随访18个月,评估2组患者抗栓治疗后出血风险和缺血性心脑血管事件。结果 389例患者中男性174例占44. 7%,女性215例占55.3%,平均年龄为77.6±11.8岁,2组的基线临床资料无明显差别。平均随访17. 8±2. 1个月后,发现2组的INR值和INR达标率均无明显差异,TT组严重出血和中度出血发生率显著高于WC组,但2组间缺血性心脑血管事件发生率无显著差异。高龄(OR=1. 57, 95%CI:1.26～1.88,P=0.007)、高HAS-BLED评分(OR=2.14,95%CI:1.46～2.77,P=0.037)和三联抗栓(OR=2.24, 95%CI:1. 73～2. 51,P=0. 012)为中重度出血的危险因素。结论在老年AF合并ACS患者治疗过程中相对联合华法林、阿司匹林及氯吡格雷的三联抗栓治疗,华法林联合氯吡格雷的二联抗栓治疗在不增加缺血性脑卒中和心血管事件情况下可降低严重和中度出血风险。高龄、高HAS-BLED评分和三联抗栓为中重度出血的危险因素。
Objectives To evaluate the effect of different anticoagulant therapy regimens in elderly patients with atrial fibrillation(AF) and acute coronary syndrome(ACS), and analysis the risk factors for bleeding.Methods This was a retrospective cohort study. 389 elderly patients(≥60 years) with AF and ACS hospitalized in Beijing Anzhen Hospital from January 2014 to December 2016 were involved. Based on the anticoagulant regimen,all elderly patients were divided into two groups : triple anticoagulant group(treated with warfarin, aspirin and clopidogrel, as TT group, n=112) and dual anticoagulant group(treated with warfarin and clopidogrel, as WC group, n=277). We compared the safety(risk of severe bleeding) and efficacy(ischemic cardiac and cerebrovascular event) between groups after 18-month follow-up. Multi-logistic regression was used to analysis the risk factors for severe bleeding. Result Of 389 elderly patients, there were 174 males(44. 7%), with a mean age of77. 6 ± 11. 8 years. Basic characteristics were similar between groups. After a mean follow-up of 17. 8 ± 2. 1 months, INR level was similar between groups, and the rates of moderate bleeding event and severe bleeding were markedly higher in the TT group. Furthermore, the rate of adverse cardiac events was comparable between groups.Multi-logistic regression showed that elderly age(OR=1. 57, 95%CI: 1. 26-1. 88, P=0. 007), HAS-BLED score(OR=2. 14, 95%CI:1. 46-2. 77, P=0. 037) and triple anticoagulant regimen(OR=2.24, 95%CI:1. 73-2. 51,P=0.012) were the risk factors for moderate-severe bleeding. Conclusions For elderly patients with AF and ACS,anticoagulant therapy with warfarin and clopidogrel is safe and effective, with decreased risk of severe bleeding and similar rate of ischemic stroke and adverse cardiac event. Elderly age, high HAS-BLED score and triple anticoagulant regimen were the risk factors for severe bleeding.
Objectives To evaluate the effect of different anticoagulant therapy regimens in elderly patients with atrial fibrillation(AF) and acute coronary syndrome(ACS), and analysis the risk factors for bleeding.Methods This was a retrospective cohort study. 389 elderly patients(≥60 years) with AF and ACS hospitalized in Beijing Anzhen Hospital from January 2014 to December 2016 were involved. Based on the anticoagulant regimen,all elderly patients were divided into two groups : triple anticoagulant group(treated with warfarin, aspirin and clopidogrel, as TT group, n=112) and dual anticoagulant group(treated with warfarin and clopidogrel, as WC group, n=277). We compared the safety(risk of severe bleeding) and efficacy(ischemic cardiac and cerebrovascular event) between groups after 18-month follow-up. Multi-logistic regression was used to analysis the risk factors for severe bleeding. Result Of 389 elderly patients, there were 174 males(44. 7%), with a mean age of77. 6 ± 11. 8 years. Basic characteristics were similar between groups. After a mean follow-up of 17. 8 ± 2. 1 months, INR level was similar between groups, and the rates of moderate bleeding event and severe bleeding were markedly higher in the TT group. Furthermore, the rate of adverse cardiac events was comparable between groups.Multi-logistic regression showed that elderly age(OR=1. 57, 95%CI: 1. 26-1. 88, P=0. 007), HAS-BLED score(OR=2. 14, 95%CI:1. 46-2. 77, P=0. 037) and triple anticoagulant regimen(OR=2.24, 95%CI:1. 73-2. 51,P=0.012) were the risk factors for moderate-severe bleeding. Conclusions For elderly patients with AF and ACS,anticoagulant therapy with warfarin and clopidogrel is safe and effective, with decreased risk of severe bleeding and similar rate of ischemic stroke and adverse cardiac event. Elderly age, high HAS-BLED score and triple anticoagulant regimen were the risk factors for severe bleeding.
引文
[1]华伟,金汉.老年心房颤动患者的抗凝管理[J].中华老年医学杂志,2017, 36(3):248-250.
[2] Wang X, Fu Q, Song F, et al. Prevalence of atrial fibrillation in different socioeconomic regions of China and its association with stroke:Results from a national stroke screening survey[J]. Int J Cardiol, 2018(271):92-97.
[3] Piccini JP, Jones WS. Triple Therapy for Atrial Fibrillation after PCI[J]. N Engl J Med. 2017, 377(16):1580-1582.
[4] January CT, Wann LS, Alpert JS, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society[J].J Am Coll Cardiol, 2014, 64(21):e1-76.
[5]张澍,杨艳敏,黄从新,等.中国心房颤动患者卒中预防规范[J].中国心律失常学杂志,2015, 19(3):162-173.
[6] Veerasamy M, Edwards R, Ford G, et al. Acute coronary syndrome among older patients:a review[J]. Cardiol Rev,2015,23(1):26-32.
[7]中华医学会老年医学分会,高龄老年冠心病诊治中国专家共识写作组.高龄老年冠心病诊治中国专家共识[J].中华老年医学杂志,2016, 35(7):683-691.
[8] Al-Khatib SM, Arshad A, Balk EM, et al. Risk Stratification for Arrhythmic Events in Patients With Asymptomatic PreExcitation:A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia:A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[J]. J Am Coll Cardiol, 2016, 67(13):1624-1638.
[9] Serebruany VL, Atar D. Assessment of bleeding events in clinical trials-proposal of a new classification[J]. Am J Cardiol, 2007, 99(2):288-290.
[10] The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators.The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation.The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators[J]. N Engl J Med, 1990, 323(22):1505-1511.
[11] Ezekowitz MD, Bridgers SL, James KE, et al.Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation.Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators[J].N Engl J Med, 1992,327(20):1406-1012.
[13] Hess CN, Peterson ED, Peng SA, et al. Use and Outcomes of Triple Therapy Among Older Patients With Acute Myocar dial Infarction and Atrial Fibrillation[J]. J Am Coll Cardiol,2015,66(6):616-627.
[14] Fox KA. Dual or single antiplatelet therapy with anticoa gulation?[J]. Lancet, 2013, 381(9872):1080-1081.
[15] Shin D, Mohanty BD, Lee ES. Dual versus triple antithro mbotic therapy after percutaneous coronary intervention or acute coronary syndrome in patients with indication for anticoagula tion:an updated meta-analysis[J]. Coron Artery Dis, 2018, 29(8):670-680.
[16]陈玉辉,盛爱珍,龚涛,等.高龄老年非瓣膜性心房颤动合并急性缺血性卒中患者临床特点分析[J].中华老年医学杂志,2018, 37(4):394-397.
[17] Goto K, Nakai K, Shizuta S, et al. CREDO-Kyoto Registry Cohort-2 Investigators. Anticoagulant and antiplatelet therapy in patients with atrial fibrillation undergoing percuta neous coronary intervention[J]. Am J Cardiol, 2014, 114(1):70-78.
[18] Ho KW, Ivanov J, Freixa X, et al. Antithrombotic therapy after coronary stenting in patients with nonvalvular atrial fibrillation[J]. Can J Cardiol, 2013, 29(2):213-218.
[2] Wang X, Fu Q, Song F, et al. Prevalence of atrial fibrillation in different socioeconomic regions of China and its association with stroke:Results from a national stroke screening survey[J]. Int J Cardiol, 2018(271):92-97.
[3] Piccini JP, Jones WS. Triple Therapy for Atrial Fibrillation after PCI[J]. N Engl J Med. 2017, 377(16):1580-1582.
[4] January CT, Wann LS, Alpert JS, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society[J].J Am Coll Cardiol, 2014, 64(21):e1-76.
[5]张澍,杨艳敏,黄从新,等.中国心房颤动患者卒中预防规范[J].中国心律失常学杂志,2015, 19(3):162-173.
[6] Veerasamy M, Edwards R, Ford G, et al. Acute coronary syndrome among older patients:a review[J]. Cardiol Rev,2015,23(1):26-32.
[7]中华医学会老年医学分会,高龄老年冠心病诊治中国专家共识写作组.高龄老年冠心病诊治中国专家共识[J].中华老年医学杂志,2016, 35(7):683-691.
[8] Al-Khatib SM, Arshad A, Balk EM, et al. Risk Stratification for Arrhythmic Events in Patients With Asymptomatic PreExcitation:A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia:A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[J]. J Am Coll Cardiol, 2016, 67(13):1624-1638.
[9] Serebruany VL, Atar D. Assessment of bleeding events in clinical trials-proposal of a new classification[J]. Am J Cardiol, 2007, 99(2):288-290.
[10] The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators.The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation.The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators[J]. N Engl J Med, 1990, 323(22):1505-1511.
[11] Ezekowitz MD, Bridgers SL, James KE, et al.Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation.Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators[J].N Engl J Med, 1992,327(20):1406-1012.
[13] Hess CN, Peterson ED, Peng SA, et al. Use and Outcomes of Triple Therapy Among Older Patients With Acute Myocar dial Infarction and Atrial Fibrillation[J]. J Am Coll Cardiol,2015,66(6):616-627.
[14] Fox KA. Dual or single antiplatelet therapy with anticoa gulation?[J]. Lancet, 2013, 381(9872):1080-1081.
[15] Shin D, Mohanty BD, Lee ES. Dual versus triple antithro mbotic therapy after percutaneous coronary intervention or acute coronary syndrome in patients with indication for anticoagula tion:an updated meta-analysis[J]. Coron Artery Dis, 2018, 29(8):670-680.
[16]陈玉辉,盛爱珍,龚涛,等.高龄老年非瓣膜性心房颤动合并急性缺血性卒中患者临床特点分析[J].中华老年医学杂志,2018, 37(4):394-397.
[17] Goto K, Nakai K, Shizuta S, et al. CREDO-Kyoto Registry Cohort-2 Investigators. Anticoagulant and antiplatelet therapy in patients with atrial fibrillation undergoing percuta neous coronary intervention[J]. Am J Cardiol, 2014, 114(1):70-78.
[18] Ho KW, Ivanov J, Freixa X, et al. Antithrombotic therapy after coronary stenting in patients with nonvalvular atrial fibrillation[J]. Can J Cardiol, 2013, 29(2):213-218.