不同抗凝强度华法林治疗非瓣膜性房颤的安全性及缺血性脑卒中发生的危险因素评估

Safety and Efficacy of Different Doses of Warfarin Anticoagulation Therapy in Non-valvular Atrial Fibrillation and Risk Factors Associated with Ischemic Stroke

关键词:  华法林  非瓣膜性心房颤动  缺血性脑卒中

Key words:  warfarin  non-valvular atrial fibrillation  ischemic stroke

摘要:

目的 评估华法林不同抗凝强度治疗非瓣膜性房颤的安全性，以及缺血性脑卒中发生的危险因素。方法 纳入2012年1月—2013年12月收治的130例非瓣膜性房颤患者，根据华法林抗凝治疗的强度分为中强度组：华法林中等强度抗凝治疗，国际标准化比率(international normalized ratio，INR)控制在2.0＜INR≤3.0；低强度组：华法林低等强度抗凝，INR控制在1.6≤INR≤2.0，记录2组患者治疗和随访期间缺血性脑卒中、出血栓塞等不良反应的发生率，ROC曲线法分析INR诊断抗凝出血风险，多因素Logistic回归分析患者缺血性脑卒中的危险因素。结果 中强度组缺血性脑卒中、短暂性脑缺血发作和外周动脉栓塞发生率分别为6.70%，3.45%和1.72%，与低强度组的8.33%，4.17%和4.17%比较，无统计学差异(P>0.05)；中强度组华法林用量(3.13±0.45)mg·d^-1，INR值2.61±0.32，出血发生率为24.14%；低强度组华法林用量(2.63±0.32)mg·d^-1，INR值 1.84±0.30，出血发生率为9.72%。采用INR诊断患者出血风险，ROC曲线下面积为0.858(95%CI：0.791~0.924)，INR的cut-off值2.85，该值下判断出血敏感性为81.1%，特异性为67.2%；多因素logistic回归分析发现年龄、合并高血压、糖尿病、心力衰竭、脑卒中病史、INR、治疗窗内时间、卒中危险评分是非瓣膜性房颤患者缺血性脑卒中发生的独立危险因素(P<0.05)。结论 中、低强度华法林抗凝治疗均有较好的抗凝效果，非瓣膜性心房颤动患者伴有血栓栓塞危险因素应尽早应用华法林抗凝治疗，严密监测INR，INR值控制在1.6≤INR≤2.0，降低和避免出血并发症。

Abstract:

OBJECTIVE To evaluate the safety and efficacy of different doses of warfarin anticoagulation therapy in non-valvular atrial fibrillation, and risk factors associated with ischemic stroke. METHODS A total of 130 patients with non-valvular atrial fibrillation from January 2012 to December 2013 were selected. patients were divided into group A with moderate intensity warfarin anticoagulation, international normalized ratio (INR) was controlled at 2.0 to 3.0, group B with low intensity warfarin anticoagulation, INR was controlled in the 1.6 to 2.0. Adverse reactions and ischemic stroke risk in two groups of patients were recorded during follow-up. INR in diagnosis of anticoagulant bleeding risk was analyzed by using ROC curve. Risk factors associated with ischemic stroke were analyzed by multivariate Logistic regression analysis. RESULTS The ischemic stroke, transient ischemic attack, peripheral arterial embolism incidence in group A was 6.70%, 3.45%, 1.72%, while it was 8.33%, 4.17%, 4.17% in the group B, the difference was not statistically significance (P>0.05). The dosage of warfarin, INR value and the incidence of bleeding in group A were (3.13±0.45)mg·d^-1, (2.61±0.32), and 24.14%, respectively, and The dosage of warfarin, INR value and the incidence of bleeding in group B were (2.63±0.32)mg·d^-1 (1.84±0.30) and 9.72% respectively. the area under the ROC curve was 0.858(95%CI: 0.791-0.924), INR's cut-off value was 2.85, sensitive and specificity in this value judgment of bleeding risk was 81.1% and 67.2%. Multivariate logistic regression analysis showed that age, hypertension, diabetes, heart failure, history of stroke, INR, TTR (time in therapeutic range), stroke risk score were independent risk factors in patients with non-valvular atrial fibrillation occurrence of ischemic stroke (P<0.05). CONCLUSION Warfarin at low or moderate doses can both prevent ischemic stroke in patients with non-valvular atrial fibrillation, and patients with risk factors associated with ischemic stroke should be treated with warfarin as early as possible. Monitoring of INR is effective to prevent possible bleeding.