伴房颤的缺血性脑血管病患者的临床特点及预后的研究
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摘要
背景缺血性卒中是一种异质性很强的临床综合征，不同病因的缺血性卒中患者其临床死亡、残疾和复发等结局存在明显不同。本研究旨在描述中国伴心房颤动的缺血性脑血管病患者临床特点，药物治疗及预后结局的现状。
方法从中国国家卒中登记研究(The China National Stroke Registry，CNSR)中选取连续入组的缺血性卒中和TIA住院患者为本研究的研究人群。中国国家卒中登记研究为一项覆盖全国132家二级和三级医院的前瞻性、观察性医院登记研究。连续入组多中心的急性脑血管病住院患者，收集患者人口学信息，临床特点及用药信息等基本资料，最长随访时间为1年，预后结局包括卒中复发、死亡及致残。用χ2检验比较缺血性卒中和TIA伴或不伴心房颤动患者基线资料及预后结局，以P<0.01为显著性差异。
结果伴房颤的缺血性卒中和TIA患者较不伴房颤的患者年龄偏高(71.24±11.74vs.64.49±12.14, P<0.01)，女性患者比例高(54.5%vs.36.3%, P<0.01)，神经功能缺损更为严重(NIHSS评分中位数:10vs.4, P<0.01)。合并症方面，伴房颤患者合并心衰(10.3%vs.0.8%, P<0.01)、冠心病(32.4%vs.11.9%, P<0.01)和周围动脉病(1.6%vs.0.5%, P<0.01)的比例较高。医疗资料利用方面，伴房颤的患者平均住院时间(15vs.14, P<0.01)和平均住院花费(10309.57vs.8055.65, P<0.01)远高于不伴房颤的患者。抗凝药物方面，伴房颤的缺血性卒中和TIA患者出院带药比例为10.1%，3个月随访时比例为11.9%，6个月随访用药比例维持在11.8%，1年随访时比例为9.1%。缺血性脑血管病患者的抗血小板药物出院带药比例为65.9%，至一年随访时抗血小板药物使用率保持在64%。其中拜阿司匹林较氯吡格雷更为常用(55.2%vs7.6%, P<0.01)，拜阿司匹林应用率是氯吡格雷应用率的7.2倍，双联抗血小板用药比例为3%。伴房颤患者的预后较不伴房颤患者的预后明显差。伴房颤的缺血性卒中和TIA患者在院死亡率接近不伴房颤患者在院死亡率的4.7倍(12.3%vs.2.6%, P<0.01)，伴房颤患者的在院复发率是不伴房颤患者的2.2倍(6.6%vs.2.9%, P<0.01)。3个月随访时，伴房颤患者3个月卒中复发率、死亡率及致残率均明显高于不伴房颤患者(复发率23.3%vs.10.0%, P<0.01；死亡率23.5%vs.5.8%,P<0.01；致残率43.6%vs.23.6%, P<0.01)。6个月及1年随访时，伴房颤患者的卒中复发率，死亡率及致残率高于不伴房颤患者(P<0.01)。
结论伴房颤的中国缺血性脑血管病患者多为高龄，女性居多，神经功能缺损严重，住院时间长、花费高，抗凝药物使用不足，其预后较不伴房颤患者差，约三分之一的缺血性脑血管病合并房颤患者在一年后死亡，一半以上患者遗留有残疾。高龄和抗凝药物应用比例较低，可能是造成伴房颤的缺血性脑血管病患者1年预后不佳的部分原因。
背景发病早期对于结局的准确预测有助于有效利用医疗资源，作出更为合理的医疗决策。缺血性卒中伴房颤患者的预后差，死亡风险高。本文旨在通过对临床预后预测模型在中国伴房颤的缺血性脑血管病患者中的预测效度的评估，寻找能够准确预测预后结局的评分工具，更好的指导临床医疗决策。
方法从中国国家卒中登记研究(The China National Stroke Registry，CNSR)中选取连续入组的缺血性卒中住院患者为本研究的研究人群，并按照是否合并心房颤动分为合并房颤和不伴房颤两组人群。收集患者人口学信息，临床特点及用药信息等基本资料，随访时间为1年，预后结局包括卒中复发及死亡。用χ2检验比较缺血性卒中伴或不伴房颤患者基线资料，以P<0.05为显著性差异。分别在伴房颤和不伴房颤两组人群中计算预测1年死亡风险的IScore评分，PLAN评分和ASTRAL评分。按照各个评分的分层标准计算各层人群死亡和卒中复发的事件发生率。采用C值表示的曲线下面积（AUC）来评价预测模型在合并房颤和不伴房颤患者中的预测效度。
结果从中国国家卒中登记数据库中选取12415位完成1年随访的缺血性卒中患者作为本研究的研究人群。其中，10847（87.37%）例患者为不伴房颤的患者，1568（12.63%）例为合并房颤的患者。总研究人群一年全因死亡的事件发生率为13.4%，伴房颤患者的1年死亡率为34.6%，不伴房颤患者的1年死亡率为10.3%。IScore评分对于总人群预测死亡的C值为0.820，在不伴房颤和伴房颤两组人群中的C值分别为0.800和0.784。PLAN评分对于总人群预测死亡的C值为0.806，在不伴房颤和伴房颤两组人群中的C值分别为0.780和0.769。ASTRAL评分对于总人群预测死亡的C值为0.823，在不伴房颤和伴房颤两组人群中的C值分别为0.798和0.793。IScore评分低危人群比例为44.26%，1年死亡事件发生率为3.4%。PLAN评分低危人群比例为8.96%，1年死亡事件发生率为2.5%。ASTRAL评分低危人群比例为17.17%，1年死亡事件发生率为2.9%。PLAN评分得到的低危患者比例最少，事件发生率最低。
结论IScore评分，PLAN评分和ASTRAL评分可针对1年死亡风险对缺血性卒中患者进行初步分层，随着评分的增高，死亡事件发生率逐渐增加。房颤患者得分偏高，房颤患者人群比例随着评分的增高而逐渐增加。各评分工具对于中国缺血性卒中患者1年死亡风险有较高的预测能力，对不伴房颤的缺血性卒中患者的预测能力略高于合并房颤的患者。在定义低危患者方面，PLAN评分优于iScore评分和ASTRAL评分。
背景对房颤患者进行栓塞事件风险分层式临床上指导抗凝药物应用的依据。CHADS2和CHA2DS2_VASc评分是非瓣膜性房颤(NVAF)患者栓塞事件风险评价的指南推荐工具，两种风险评价工具应用于卒中二级预防的证据不足。本研究将探讨CHADS2和CHA2DS2_VASc评分对缺血性卒中和TIA合并非瓣膜性的患者一年卒中复发、致残及死亡风险的预测能力。
方法从中国国家卒中登记研究(The China National Stroke Registry，CNSR)中选取缺血性卒中和TIA伴非瓣膜性房颤的住院患者为本研究的研究人群。以1年随访的预后结局为终点事件，包括1年的卒中复发、致残及死亡。采用C值表示的曲线下面积（AUC）来评价CHADS2和CHA2DS2_VASc评分的对预测1年卒中复发、致残和死亡的效度。用Logistic回归进行单因素和多因素分析，寻找影响研究人群不良预后的危险因素。根据影响预后的独立危险因素结果对CHADS2和CHA2DS2_VASc评分进行改进，采用C值表示的曲线下面积在产生队列中评价新工具的预测能力。
结果从中国国家卒中登记数据库中连续入组的22216位急性血管壁患者中筛选出1297位完成了1年随访的缺血性卒中和TIA合并非瓣膜性房颤的患者。对1297位患者基线资料及1年预后的结果分析得出：CHADS2和CHA2DS2_VASc评分对卒中复发的C值分别为0.532(OR1.150,95%CI:1.005-1.315)和0.551(OR1.138,95%CI:1.045-1.240)，对死亡的C值分别为0.525(OR1.122,95%CI:0.987-1.276)和0.574(OR1.201,95%CI:1.105-1.305)，对残疾的C值分别为0.542(OR1.195,95%CI:1.023-1.397)和0.593(OR1.276,95%CI:1.156-1.409)。多因素分析结果发现高龄(年龄≥75岁)和严重卒中(NIHSS≥15分)是影响预后的独立危险因素。在CHADS2和CHA2DS2_VASc评分基础上加入基线NIHSS评分，组成CHADS2N和CHA2DS2_VASc N评分，两种新的评分工具对一年卒中复发的C值分别为0.578(OR1.250,95%CI:1.137-1.374)和0.580(OR1.185,95%CI:1.105-1.272)，对死亡的C值分别为0.691(OR1.183,95%CI:1.635-2.010)和0.689(OR1.528,95%CI:1.023-1.397)，对残疾的C值分别为0.668(OR1.184295%CI:1.603-2.116) and0.681(OR1.579,95%CI:1.430-1.743)。
结论CHADS2和CHA2DS2_VASc评分在预测中国缺血性卒中和TIA合并非瓣膜性房颤患者的一年预后危险分层方面能力有限。基线NIHSS评分作为不良预后的独立危险因素，加入到两种评分工具中形成CHADS2N和CHA2DS2_VAScN评分。新评分可提高预测能力，且不增加评分难度，在临床工作中能够更好的指导非瓣膜性房颤患者抗凝药物的应用。
Background Ischemic stroke is a kind of clinical syndrome with strong heterogeneity,and different etiology results in different prognosis such as stroke recurrence, deathand disability. This study was to explore the clinical characteristics and prognosis ofischemic stroke and TIA patients with atrial fibrillation (AF) in China.
Methods Selecting hospitalized patients with ischemic Stroke or TIA from CNSR(The China National Stroke Registry, CNSR) as the study population for this research.The China National Stroke Registry is a nationwide, prospective, observationalregistration including132secondary and tertiary hospitals. It has enrolled multicenterhospitalized patients with acute cerebrovascular disease, collecting patients’ basicdata such as demographic information, clinical characteristics and drug information.The longest follow-up is1year. Prognostic outcome includes stroke recurrence, deathand vascular events. The chi-square test was used to compare the baseline data andoutcomes between ischemic stroke and TIA patients with or without AF, P <0.01asthe significant difference.
Results Comparing clinical characteristics and prognosis between ischemic stroke andTIA patients with or without AF in China, we could find patients with AF are older(71.24±11.74vs.64.49±12.14, P <0.01), with higher proportion of women (54.5%vs.36.3%, P <0.01) and more severe neurologic deficits (NIHSS score: median10vs.4,P <0.01). On the aspect of complications, the prevalence rates of congestive heartfailure (10.3%vs.0.8%, P <0.01), coronary heart disease (32.4%vs.11.9%, P <0.01)and peripheral arterial disease (1.6%vs.0.5%, P <0.01) were higher in patients withAF. On the aspect of the use of medical resources, the average length of hospital stay(15vs.14, P<0.01) and hospitalization cost (10309.57vs.8055.65, P<0.01) ofpatients with AF was much higher than patients without AF.On the aspect of anticoagulant drugs, the patients with AF’s usage of warfarin was10.3%at discharge.Compared with11.9%at the time of3months’ follow-up,6months’ follow-upremained at11.8%and at1year follow-up was9.1%.65.9%of Ischemic stroke orTIA patients have antiplatelet drugs overall. The utilization rate of antiplatelet drug atthe time of one year follow-up was at64%. Compared to clopidogrel, aspirin is morecommonly used (55.2%vs7.6%, P <0.01), the rate of dual antiplatelet therapy was3%. The prognosis of ischemic stroke and TIA patients with or without atrialfibrillation AF in China are obvious different. The hospital mortality rates of ischemicstroke or TIA patients with AF was as4.7times as that in patients without AF (12.3%vs.2.6%), and the stroke recurrence rate in hospital of AF patients was2.2time asthat in patients without AF (6.6%vs.2.9%, P<0.01). At the3months follow-up, therates of stroke recurrence, disability and mortality of patients with AF were higherthan patients without AF (the rate of stroke recurrence23.3%vs.10.0%, P<0.01;mortality23.5%vs.5.8%, P<0.01; the rate of disability43.6%vs.23.6%, P<0.01).6months and1year follow-up showed the the rates of stroke recurrence, disability andmortality of patients with AF were higher than patients without AF (P<0.01).
Conclusions In China, ischemic stroke and TIA patients with AF are older, morefemale predominance, more severe neurologic deficits, longer hospital stays, higherhospitalization costs and lower utilization ratio of warfarin than patients without AF.The prognosis in patients with AF is poor, about a third patients died after one year,and more than half of the patients suffered disabilities. The advanced age and lowproportion of anticoagulant drugs use might contribute to the poor outcome of AFpatients.
Background Prognosis assessment on the early stage is helpful to make morereasonable decisions of medical treatment. The risk of death is higher for ischemicstroke patients with atrial fibrillation (AF). The aim of the study is to assess the valueof the predictive models in Chinese ischemic stroke patients with AF and to givebetter instruction of medical decisions.
Methods Patients with ischemic Stroke selected from CNSR (The China NationalStroke Registry, CNSR) were divided into AF group and non-AF group.Demographic information, clinical characteristics and drug information werecollected. One year stroke recurrence and death were the main outcome measures.Using chi-square test compared the baseline data for patients with ischemic strokewith or without AF, with P <0.05as the significant difference. Calculated IScorescores, PLAN scores and ASTRAL scores. The C statistic was used to assess thevalue of prediction for the three risk scores in different groups.
Results12415ischemic stroke patients were selected from22216acutecerebrovascular disease patients who were enrolled in the CNSR study. The ischemicstroke patients were composed of10847(87.37%）non-AF patients and1568（12.63%）AF patients. The ischemic patients’1year mortality was13.4%, while mortality ofpatients with AF was34.6%and patients without AF was10.3%. The C statistic ofIScore score was0.820for ischemic stroke patients,0.800for patients without AF and0.784for patients with AF. The C statistic of PLAN score was0.806for ischemicstroke patients,0.780for patients without AF and0.769for patients with AF. The Cstatistic of ASTRAL score was0.823for ischemic stroke patients,0.798for patientswithout AF and0.793for patients with AF. IScore score distinguished44.26%low-risk patients with the1mortality of3.4%. PLAN score distinguished8.96% low-risk patients with the1mortality of2.5%. ASTRAL score distinguished17.17%low-risk patients with the1mortality of2.9%.Conclusions IScore score, PLAN score and ASTRAL score could preliminary stratifyischemic stroke patients based on the risk of1year death. The event rates increasedwith the increase of score. IScore score, PLAN score and ASTRAL score performedwell in1year prediction of death. The validation of all risk scores in patients withoutAF was higher than in patients with AF. PLAN score is superior to IScore score andASTRAL score for distinguishing the low-risk patients.
Background Great efforts have been directed toward risk stratification to identifypatients with atrial fibrillation at highest risk. We investigated if CHADS2andCHA2DS2-VASc scores, which are associated with stroke risk in patients withnon-valvular atrial fibrillation (NVAF), could be used to predict one year prognosis instroke recurrence, mortality and disability of ischemic stroke or transient ischemicattack (TIA) patients with NVAF for secondary prevention of stroke.
Methods Ischemic stroke or transient ischemic attack (TIA) patients with NVAF wereselected from The China National Stroke Registry (CNSR). One year strokerecurrence, death and dependence were the main outcome measures.The C statisticwas calculated to assess Clinical prediction of the CHADS2and CHA2DS2-VAScscores. Univariate and multivariate logistic regressions were performed to analyze therelevant risk factors. Based on the results of the logistic regressions, modified thestratified scores and testing the new stratified scores by using C statistic.
Results1297patients with NVAF were selected from22216acute cerebrovasculardisease patients who were enrolled in the CNSR study. All selected patients werecompleted1year follow-up. For stroke recurrence rate, the C statistic value was0.53(odds ratio [OR]1.15,95%confidence interval [CI]:1.01to1.32) for CHADS2and0.55(OR1.14,95%CI:1.05to1.24) for CHA2DS2-VASc.For all-cause mortality,theC statistic value was0.525(OR1.122,95%CI:0.987to1.276) for CHADS2,and0.574(OR1.201,95%CI:1.105to1.305) for CHA2DS2-VASc. For disability rate,the C statistic value was0.542(OR1.195,95%CI:1.023to1.397), and0.593(OR1.276,95%CI:1.156to1.409)for these two scores respectively.The multivariatelogistic-regression analysisdemonstrated thatolder age (≥75years) and a higher NIHSS score(≥15) were associated with ahigher risk for one-year strokerecurrencewith the adjusted odds ratio of1.659(95%CI:1.144to2.405) and1.886(95%CI:1.341to2.653) after controlling other confounders. These two risk factorswere also associated with the all-cause death (OR2.167,95%CI:1.417to3.317forage≥75years; OR7.916,95%CI:5.435to11.529for the NIHSS score≥15) anddisability (OR2.322,95%CI:1.500to3.594for age≥75years; OR14.829,95%CI:7.762to28.330for the NIHSS score≥15).After adding NIHSS into the riskstratification scores, the C statistic values of CHADS2N and CHA2DS2-VAScNwere0.578(OR1.250,95%CI:1.137to1.374) and0.580(OR1.185,95%CI:1.105to1.272) for stroke recurrence rate,0.691(OR1.183,95%CI:1.635to2.010) and0.689(OR1.528,95%CI:1.023to1.397)for all-cause mortality, and0.668(OR1.184295%CI:1.603to2.116) and0.681(OR1.579,95%CI:1.430to1.743) for disability rate,respectively.
`Conclusions Both CHADS2and CHA2DS2-VASc scores have limitations inpredicting the one-year prognosis ofstroke/TIA patients with NVAF in china. NIHSSscore, as the independent risk factor of poor outcomes, was added to these twostratified scores in order to improve the predictive value of stratified scores, while didnot increase the difficulty of the standards of scoring.
方法从中国国家卒中登记研究(The China National Stroke Registry，CNSR)中选取连续入组的缺血性卒中和TIA住院患者为本研究的研究人群。中国国家卒中登记研究为一项覆盖全国132家二级和三级医院的前瞻性、观察性医院登记研究。连续入组多中心的急性脑血管病住院患者，收集患者人口学信息，临床特点及用药信息等基本资料，最长随访时间为1年，预后结局包括卒中复发、死亡及致残。用χ2检验比较缺血性卒中和TIA伴或不伴心房颤动患者基线资料及预后结局，以P<0.01为显著性差异。
结果伴房颤的缺血性卒中和TIA患者较不伴房颤的患者年龄偏高(71.24±11.74vs.64.49±12.14, P<0.01)，女性患者比例高(54.5%vs.36.3%, P<0.01)，神经功能缺损更为严重(NIHSS评分中位数:10vs.4, P<0.01)。合并症方面，伴房颤患者合并心衰(10.3%vs.0.8%, P<0.01)、冠心病(32.4%vs.11.9%, P<0.01)和周围动脉病(1.6%vs.0.5%, P<0.01)的比例较高。医疗资料利用方面，伴房颤的患者平均住院时间(15vs.14, P<0.01)和平均住院花费(10309.57vs.8055.65, P<0.01)远高于不伴房颤的患者。抗凝药物方面，伴房颤的缺血性卒中和TIA患者出院带药比例为10.1%，3个月随访时比例为11.9%，6个月随访用药比例维持在11.8%，1年随访时比例为9.1%。缺血性脑血管病患者的抗血小板药物出院带药比例为65.9%，至一年随访时抗血小板药物使用率保持在64%。其中拜阿司匹林较氯吡格雷更为常用(55.2%vs7.6%, P<0.01)，拜阿司匹林应用率是氯吡格雷应用率的7.2倍，双联抗血小板用药比例为3%。伴房颤患者的预后较不伴房颤患者的预后明显差。伴房颤的缺血性卒中和TIA患者在院死亡率接近不伴房颤患者在院死亡率的4.7倍(12.3%vs.2.6%, P<0.01)，伴房颤患者的在院复发率是不伴房颤患者的2.2倍(6.6%vs.2.9%, P<0.01)。3个月随访时，伴房颤患者3个月卒中复发率、死亡率及致残率均明显高于不伴房颤患者(复发率23.3%vs.10.0%, P<0.01；死亡率23.5%vs.5.8%,P<0.01；致残率43.6%vs.23.6%, P<0.01)。6个月及1年随访时，伴房颤患者的卒中复发率，死亡率及致残率高于不伴房颤患者(P<0.01)。
结论伴房颤的中国缺血性脑血管病患者多为高龄，女性居多，神经功能缺损严重，住院时间长、花费高，抗凝药物使用不足，其预后较不伴房颤患者差，约三分之一的缺血性脑血管病合并房颤患者在一年后死亡，一半以上患者遗留有残疾。高龄和抗凝药物应用比例较低，可能是造成伴房颤的缺血性脑血管病患者1年预后不佳的部分原因。
背景发病早期对于结局的准确预测有助于有效利用医疗资源，作出更为合理的医疗决策。缺血性卒中伴房颤患者的预后差，死亡风险高。本文旨在通过对临床预后预测模型在中国伴房颤的缺血性脑血管病患者中的预测效度的评估，寻找能够准确预测预后结局的评分工具，更好的指导临床医疗决策。
方法从中国国家卒中登记研究(The China National Stroke Registry，CNSR)中选取连续入组的缺血性卒中住院患者为本研究的研究人群，并按照是否合并心房颤动分为合并房颤和不伴房颤两组人群。收集患者人口学信息，临床特点及用药信息等基本资料，随访时间为1年，预后结局包括卒中复发及死亡。用χ2检验比较缺血性卒中伴或不伴房颤患者基线资料，以P<0.05为显著性差异。分别在伴房颤和不伴房颤两组人群中计算预测1年死亡风险的IScore评分，PLAN评分和ASTRAL评分。按照各个评分的分层标准计算各层人群死亡和卒中复发的事件发生率。采用C值表示的曲线下面积（AUC）来评价预测模型在合并房颤和不伴房颤患者中的预测效度。
结果从中国国家卒中登记数据库中选取12415位完成1年随访的缺血性卒中患者作为本研究的研究人群。其中，10847（87.37%）例患者为不伴房颤的患者，1568（12.63%）例为合并房颤的患者。总研究人群一年全因死亡的事件发生率为13.4%，伴房颤患者的1年死亡率为34.6%，不伴房颤患者的1年死亡率为10.3%。IScore评分对于总人群预测死亡的C值为0.820，在不伴房颤和伴房颤两组人群中的C值分别为0.800和0.784。PLAN评分对于总人群预测死亡的C值为0.806，在不伴房颤和伴房颤两组人群中的C值分别为0.780和0.769。ASTRAL评分对于总人群预测死亡的C值为0.823，在不伴房颤和伴房颤两组人群中的C值分别为0.798和0.793。IScore评分低危人群比例为44.26%，1年死亡事件发生率为3.4%。PLAN评分低危人群比例为8.96%，1年死亡事件发生率为2.5%。ASTRAL评分低危人群比例为17.17%，1年死亡事件发生率为2.9%。PLAN评分得到的低危患者比例最少，事件发生率最低。
结论IScore评分，PLAN评分和ASTRAL评分可针对1年死亡风险对缺血性卒中患者进行初步分层，随着评分的增高，死亡事件发生率逐渐增加。房颤患者得分偏高，房颤患者人群比例随着评分的增高而逐渐增加。各评分工具对于中国缺血性卒中患者1年死亡风险有较高的预测能力，对不伴房颤的缺血性卒中患者的预测能力略高于合并房颤的患者。在定义低危患者方面，PLAN评分优于iScore评分和ASTRAL评分。
背景对房颤患者进行栓塞事件风险分层式临床上指导抗凝药物应用的依据。CHADS2和CHA2DS2_VASc评分是非瓣膜性房颤(NVAF)患者栓塞事件风险评价的指南推荐工具，两种风险评价工具应用于卒中二级预防的证据不足。本研究将探讨CHADS2和CHA2DS2_VASc评分对缺血性卒中和TIA合并非瓣膜性的患者一年卒中复发、致残及死亡风险的预测能力。
方法从中国国家卒中登记研究(The China National Stroke Registry，CNSR)中选取缺血性卒中和TIA伴非瓣膜性房颤的住院患者为本研究的研究人群。以1年随访的预后结局为终点事件，包括1年的卒中复发、致残及死亡。采用C值表示的曲线下面积（AUC）来评价CHADS2和CHA2DS2_VASc评分的对预测1年卒中复发、致残和死亡的效度。用Logistic回归进行单因素和多因素分析，寻找影响研究人群不良预后的危险因素。根据影响预后的独立危险因素结果对CHADS2和CHA2DS2_VASc评分进行改进，采用C值表示的曲线下面积在产生队列中评价新工具的预测能力。
结果从中国国家卒中登记数据库中连续入组的22216位急性血管壁患者中筛选出1297位完成了1年随访的缺血性卒中和TIA合并非瓣膜性房颤的患者。对1297位患者基线资料及1年预后的结果分析得出：CHADS2和CHA2DS2_VASc评分对卒中复发的C值分别为0.532(OR1.150,95%CI:1.005-1.315)和0.551(OR1.138,95%CI:1.045-1.240)，对死亡的C值分别为0.525(OR1.122,95%CI:0.987-1.276)和0.574(OR1.201,95%CI:1.105-1.305)，对残疾的C值分别为0.542(OR1.195,95%CI:1.023-1.397)和0.593(OR1.276,95%CI:1.156-1.409)。多因素分析结果发现高龄(年龄≥75岁)和严重卒中(NIHSS≥15分)是影响预后的独立危险因素。在CHADS2和CHA2DS2_VASc评分基础上加入基线NIHSS评分，组成CHADS2N和CHA2DS2_VASc N评分，两种新的评分工具对一年卒中复发的C值分别为0.578(OR1.250,95%CI:1.137-1.374)和0.580(OR1.185,95%CI:1.105-1.272)，对死亡的C值分别为0.691(OR1.183,95%CI:1.635-2.010)和0.689(OR1.528,95%CI:1.023-1.397)，对残疾的C值分别为0.668(OR1.184295%CI:1.603-2.116) and0.681(OR1.579,95%CI:1.430-1.743)。
结论CHADS2和CHA2DS2_VASc评分在预测中国缺血性卒中和TIA合并非瓣膜性房颤患者的一年预后危险分层方面能力有限。基线NIHSS评分作为不良预后的独立危险因素，加入到两种评分工具中形成CHADS2N和CHA2DS2_VAScN评分。新评分可提高预测能力，且不增加评分难度，在临床工作中能够更好的指导非瓣膜性房颤患者抗凝药物的应用。
Background Ischemic stroke is a kind of clinical syndrome with strong heterogeneity,and different etiology results in different prognosis such as stroke recurrence, deathand disability. This study was to explore the clinical characteristics and prognosis ofischemic stroke and TIA patients with atrial fibrillation (AF) in China.
Methods Selecting hospitalized patients with ischemic Stroke or TIA from CNSR(The China National Stroke Registry, CNSR) as the study population for this research.The China National Stroke Registry is a nationwide, prospective, observationalregistration including132secondary and tertiary hospitals. It has enrolled multicenterhospitalized patients with acute cerebrovascular disease, collecting patients’ basicdata such as demographic information, clinical characteristics and drug information.The longest follow-up is1year. Prognostic outcome includes stroke recurrence, deathand vascular events. The chi-square test was used to compare the baseline data andoutcomes between ischemic stroke and TIA patients with or without AF, P <0.01asthe significant difference.
Results Comparing clinical characteristics and prognosis between ischemic stroke andTIA patients with or without AF in China, we could find patients with AF are older(71.24±11.74vs.64.49±12.14, P <0.01), with higher proportion of women (54.5%vs.36.3%, P <0.01) and more severe neurologic deficits (NIHSS score: median10vs.4,P <0.01). On the aspect of complications, the prevalence rates of congestive heartfailure (10.3%vs.0.8%, P <0.01), coronary heart disease (32.4%vs.11.9%, P <0.01)and peripheral arterial disease (1.6%vs.0.5%, P <0.01) were higher in patients withAF. On the aspect of the use of medical resources, the average length of hospital stay(15vs.14, P<0.01) and hospitalization cost (10309.57vs.8055.65, P<0.01) ofpatients with AF was much higher than patients without AF.On the aspect of anticoagulant drugs, the patients with AF’s usage of warfarin was10.3%at discharge.Compared with11.9%at the time of3months’ follow-up,6months’ follow-upremained at11.8%and at1year follow-up was9.1%.65.9%of Ischemic stroke orTIA patients have antiplatelet drugs overall. The utilization rate of antiplatelet drug atthe time of one year follow-up was at64%. Compared to clopidogrel, aspirin is morecommonly used (55.2%vs7.6%, P <0.01), the rate of dual antiplatelet therapy was3%. The prognosis of ischemic stroke and TIA patients with or without atrialfibrillation AF in China are obvious different. The hospital mortality rates of ischemicstroke or TIA patients with AF was as4.7times as that in patients without AF (12.3%vs.2.6%), and the stroke recurrence rate in hospital of AF patients was2.2time asthat in patients without AF (6.6%vs.2.9%, P<0.01). At the3months follow-up, therates of stroke recurrence, disability and mortality of patients with AF were higherthan patients without AF (the rate of stroke recurrence23.3%vs.10.0%, P<0.01;mortality23.5%vs.5.8%, P<0.01; the rate of disability43.6%vs.23.6%, P<0.01).6months and1year follow-up showed the the rates of stroke recurrence, disability andmortality of patients with AF were higher than patients without AF (P<0.01).
Conclusions In China, ischemic stroke and TIA patients with AF are older, morefemale predominance, more severe neurologic deficits, longer hospital stays, higherhospitalization costs and lower utilization ratio of warfarin than patients without AF.The prognosis in patients with AF is poor, about a third patients died after one year,and more than half of the patients suffered disabilities. The advanced age and lowproportion of anticoagulant drugs use might contribute to the poor outcome of AFpatients.
Background Prognosis assessment on the early stage is helpful to make morereasonable decisions of medical treatment. The risk of death is higher for ischemicstroke patients with atrial fibrillation (AF). The aim of the study is to assess the valueof the predictive models in Chinese ischemic stroke patients with AF and to givebetter instruction of medical decisions.
Methods Patients with ischemic Stroke selected from CNSR (The China NationalStroke Registry, CNSR) were divided into AF group and non-AF group.Demographic information, clinical characteristics and drug information werecollected. One year stroke recurrence and death were the main outcome measures.Using chi-square test compared the baseline data for patients with ischemic strokewith or without AF, with P <0.05as the significant difference. Calculated IScorescores, PLAN scores and ASTRAL scores. The C statistic was used to assess thevalue of prediction for the three risk scores in different groups.
Results12415ischemic stroke patients were selected from22216acutecerebrovascular disease patients who were enrolled in the CNSR study. The ischemicstroke patients were composed of10847(87.37%）non-AF patients and1568（12.63%）AF patients. The ischemic patients’1year mortality was13.4%, while mortality ofpatients with AF was34.6%and patients without AF was10.3%. The C statistic ofIScore score was0.820for ischemic stroke patients,0.800for patients without AF and0.784for patients with AF. The C statistic of PLAN score was0.806for ischemicstroke patients,0.780for patients without AF and0.769for patients with AF. The Cstatistic of ASTRAL score was0.823for ischemic stroke patients,0.798for patientswithout AF and0.793for patients with AF. IScore score distinguished44.26%low-risk patients with the1mortality of3.4%. PLAN score distinguished8.96% low-risk patients with the1mortality of2.5%. ASTRAL score distinguished17.17%low-risk patients with the1mortality of2.9%.Conclusions IScore score, PLAN score and ASTRAL score could preliminary stratifyischemic stroke patients based on the risk of1year death. The event rates increasedwith the increase of score. IScore score, PLAN score and ASTRAL score performedwell in1year prediction of death. The validation of all risk scores in patients withoutAF was higher than in patients with AF. PLAN score is superior to IScore score andASTRAL score for distinguishing the low-risk patients.
Background Great efforts have been directed toward risk stratification to identifypatients with atrial fibrillation at highest risk. We investigated if CHADS2andCHA2DS2-VASc scores, which are associated with stroke risk in patients withnon-valvular atrial fibrillation (NVAF), could be used to predict one year prognosis instroke recurrence, mortality and disability of ischemic stroke or transient ischemicattack (TIA) patients with NVAF for secondary prevention of stroke.
Methods Ischemic stroke or transient ischemic attack (TIA) patients with NVAF wereselected from The China National Stroke Registry (CNSR). One year strokerecurrence, death and dependence were the main outcome measures.The C statisticwas calculated to assess Clinical prediction of the CHADS2and CHA2DS2-VAScscores. Univariate and multivariate logistic regressions were performed to analyze therelevant risk factors. Based on the results of the logistic regressions, modified thestratified scores and testing the new stratified scores by using C statistic.
Results1297patients with NVAF were selected from22216acute cerebrovasculardisease patients who were enrolled in the CNSR study. All selected patients werecompleted1year follow-up. For stroke recurrence rate, the C statistic value was0.53(odds ratio [OR]1.15,95%confidence interval [CI]:1.01to1.32) for CHADS2and0.55(OR1.14,95%CI:1.05to1.24) for CHA2DS2-VASc.For all-cause mortality,theC statistic value was0.525(OR1.122,95%CI:0.987to1.276) for CHADS2,and0.574(OR1.201,95%CI:1.105to1.305) for CHA2DS2-VASc. For disability rate,the C statistic value was0.542(OR1.195,95%CI:1.023to1.397), and0.593(OR1.276,95%CI:1.156to1.409)for these two scores respectively.The multivariatelogistic-regression analysisdemonstrated thatolder age (≥75years) and a higher NIHSS score(≥15) were associated with ahigher risk for one-year strokerecurrencewith the adjusted odds ratio of1.659(95%CI:1.144to2.405) and1.886(95%CI:1.341to2.653) after controlling other confounders. These two risk factorswere also associated with the all-cause death (OR2.167,95%CI:1.417to3.317forage≥75years; OR7.916,95%CI:5.435to11.529for the NIHSS score≥15) anddisability (OR2.322,95%CI:1.500to3.594for age≥75years; OR14.829,95%CI:7.762to28.330for the NIHSS score≥15).After adding NIHSS into the riskstratification scores, the C statistic values of CHADS2N and CHA2DS2-VAScNwere0.578(OR1.250,95%CI:1.137to1.374) and0.580(OR1.185,95%CI:1.105to1.272) for stroke recurrence rate,0.691(OR1.183,95%CI:1.635to2.010) and0.689(OR1.528,95%CI:1.023to1.397)for all-cause mortality, and0.668(OR1.184295%CI:1.603to2.116) and0.681(OR1.579,95%CI:1.430to1.743) for disability rate,respectively.
`Conclusions Both CHADS2and CHA2DS2-VASc scores have limitations inpredicting the one-year prognosis ofstroke/TIA patients with NVAF in china. NIHSSscore, as the independent risk factor of poor outcomes, was added to these twostratified scores in order to improve the predictive value of stratified scores, while didnot increase the difficulty of the standards of scoring.
引文
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