房颤患者服用华法林抗凝质量的影响因素
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摘要
目的分析房颤患者服用华法林抗凝质量的影响因素及其与不良事件的关系。方法对251例长期服用华法林抗凝的房颤患者,进行国际标准化比值(INR)的收集和出血、栓塞及死亡事件的跟踪随访。以INR在治疗目标范围内的时间百分比(TTR)来反映华法林抗凝质量。结果 251例患者平均TTR值仅为32.4%,只有12.0%的患者获得高水平抗凝质量(TTR≥65%)。Logistic回归分析显示年龄<60岁(OR=2.911)和脑卒中史(OR=5.608)是低质量抗凝的影响因素。不同抗凝质量组不良事件发生率比较,差异无统计学意义(均P>0.05),但不良事件均发生在TTR<65%的患者。结论房颤患者服用华法林抗凝质量差,远低于有效的抗凝水平。医护人员需对年龄<60岁、脑卒中史和TTR<65%的患者加强抗凝管理,改善抗凝质量,减少不良事件的发生。
Objective To explore factors associated with the quality of warfarin anticoagulation, and the relationship between quality of warfarin anticoagulation and adverse events in patients with atrial fibrillation.Methods Totally, 251 patients with atrial fibrillation(AF) on warfarin therapy were followed up, and data such as international normalized ratios(INRs) and adverse events including bleeding, embolism and deaths were collected during follow-up. Quality of warfarin anticoagulation was reflected as time in therapeutic range(TTR).Results The included patients had an average TTR of 32.4%, and only 12.0% enjoyed a high quality of warfarin anticoagulation(TTR≥65%). Logistic regression analysis showed that, age<60 years(OR=2.911) and previous stroke(OR=5.608) were associated with poor quality of warfarin anticoagulation.The incidence rates of adverse events had no significant differences between the high quality and low quality groups. However, all types of adverse events occurred in the low quality group.Conclusion The quality of warfarin anticoagulation in patients with AF was poor,being far below an effective anticoagulation level.To improve the quality of warfarin anticoagulation and reduce the incidence rates of adverse events, medical staffs should strengthen management of anticoagulation for patients under 60 years of age, those with previous stroke and those with TTR<65%.
Objective To explore factors associated with the quality of warfarin anticoagulation, and the relationship between quality of warfarin anticoagulation and adverse events in patients with atrial fibrillation.Methods Totally, 251 patients with atrial fibrillation(AF) on warfarin therapy were followed up, and data such as international normalized ratios(INRs) and adverse events including bleeding, embolism and deaths were collected during follow-up. Quality of warfarin anticoagulation was reflected as time in therapeutic range(TTR).Results The included patients had an average TTR of 32.4%, and only 12.0% enjoyed a high quality of warfarin anticoagulation(TTR≥65%). Logistic regression analysis showed that, age<60 years(OR=2.911) and previous stroke(OR=5.608) were associated with poor quality of warfarin anticoagulation.The incidence rates of adverse events had no significant differences between the high quality and low quality groups. However, all types of adverse events occurred in the low quality group.Conclusion The quality of warfarin anticoagulation in patients with AF was poor,being far below an effective anticoagulation level.To improve the quality of warfarin anticoagulation and reduce the incidence rates of adverse events, medical staffs should strengthen management of anticoagulation for patients under 60 years of age, those with previous stroke and those with TTR<65%.
引文
[1] Lip G,Freedman B,De Caterina R,et al.Stroke prevention in atrial fibrillation:past,present and future.Comparing the guidelines and practical decision-making[J].Thromb Haemost,2017,117(7):1230-1239.
[2] 张澍,杨艳敏,黄从新,等.中国心房颤动患者卒中预防规范(2017)[J].中华心律失常学杂志,2018,22(1):17-30.
[3] Kirchhof P,Benussi S,Kotecha D,et al.2016 ESC guidelines for the management of atrial fibrillation deve-loped in collaboration with EACTS[J].Europace,2016,18(11):1609-1678.
[4] 王志尊,王伟,杜昕,等.非瓣膜病心房颤动患者华法林长期抗凝治疗的依从性[J].中华心血管病杂志,2017,45(11):920-923.
[5] Jones C,Pollit V,Fitzmaurice D,et al.The management of atrial fibrillation:summary of updated NICE guidance[J].BMJ,2014,348:g3655.
[6] 中华医学会心血管病学分会,中国老年学学会心脑血管病专业委员会.华法林抗凝治疗的中国专家共识[J].中华内科杂志,2013,52(1):76-82.
[7] 向伟,王禹川,刘芳,等.CHADS2评分与CHA2DS2-VASc评分优劣性比较[J].中华心血管病杂志,2014,42(5):389-391.
[8] Rosendaal F R,Cannegieter S C,van der Meer F J,et al.A method to determine the optimal intensity of oral anticoagulant therapy[J].Thromb Haemost,1993,69(3):236-239.
[9] Chan P H,Hai J J,Chan E W,et al.Use of the SAMe-TT2R2 Score to predict good anticoagulation control with warfarin in Chinese patients with atrial fibrillation:relationship to ischemic stroke incidence[J].PLoS One,2016,11(3):e150674.
[10] Oldgren J,Healey J S,Ezekowitz M,et al.Variations in cause and management of atrial fibrillation in a prospective registry of 15,400 emergency department patients in 46 countries:the RE-LY Atrial Fibrillation Registry[J].Circulation,2014,129(15):1568-1576.
[11] 孙艺红,胡大一.非瓣膜病心房颤动患者全球抗凝注册研究中国亚组基线数据分析[J].中华心血管病杂志,2014,42(10):846-850.
[12] Apostolakis S,Sullivan R M,Olshansky B,et al.Factors affecting quality of anticoagulation control among patients with atrial fibrillation on warfarin:the SAMe-TT(2)R(2) score[J].Chest,2013,144(5):1555-1563.
[13] 刘晓燕,郭晴晴,张群.瓣膜术后口服华法林患者的延续护理[J].护理学杂志,2017,32(22):93-96.
[14] Ruff C T,Giugliano R P,Braunwald E,et al.Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation:a meta-analysis of randomised trials[J].Lancet,2014,383(9921):955-962.
[15] Macedo A F,Bell J,Mccarron C,et al.Determinants of oral anticoagulation control in new warfarin patients:analysis using data from Clinical Practice Research Data-link[J].Thrombosis Research,2015,136(2):250-260.
[16] 夏沪露,张晓艳,蒋凌燕,等.回馈教学在华法林治疗房颤患者健康教育中的应用[J].护理学杂志,2017,32(13):21-23.
[17] Nathisuwan S,Dilokthornsakul P,Chaiyakunapruk N,et al.Assessing evidence of interaction between smoking and warfarin:a systematic review and meta-analysis[J].Chest,2011,139(5):1130-1139.
[18] Vestergaard A S,Skj?th F,Larsen T B,et al.The importance of mean time in therapeutic range for complication rates in warfarin therapy of patients with atrial fibrillation:a systematic review and meta-regression analysis[J].PLoS One,2017,12(11):e0188482.
[19] Veeger N J,Piersma-Wichers M,Tijssen J G,et al.Individual time within target range in patients treated with vitamin K antagonists:main determinant of quality of anticoagulation and predictor of clinical outcome.A retrospective study of 2300 consecutive patients with venous thromboembolism[J].Br J Haematol,2005,128(4):513-519.
[20] Heneghan C,Ward A,Perera R,et al.Self-monitoring of oral anticoagulation:systematic review and meta-analysis of individual patient data[J].Lancet,2012,379(9813):322-334.
[21] Holbrook A,Schulman S,Witt D M,et al.Evidence-based management of anticoagulant therapy:Antithrombotic Therapy and Prevention of Thrombosis,9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J].Chest,2012,141(2 Suppl):e152S-e184S.
[2] 张澍,杨艳敏,黄从新,等.中国心房颤动患者卒中预防规范(2017)[J].中华心律失常学杂志,2018,22(1):17-30.
[3] Kirchhof P,Benussi S,Kotecha D,et al.2016 ESC guidelines for the management of atrial fibrillation deve-loped in collaboration with EACTS[J].Europace,2016,18(11):1609-1678.
[4] 王志尊,王伟,杜昕,等.非瓣膜病心房颤动患者华法林长期抗凝治疗的依从性[J].中华心血管病杂志,2017,45(11):920-923.
[5] Jones C,Pollit V,Fitzmaurice D,et al.The management of atrial fibrillation:summary of updated NICE guidance[J].BMJ,2014,348:g3655.
[6] 中华医学会心血管病学分会,中国老年学学会心脑血管病专业委员会.华法林抗凝治疗的中国专家共识[J].中华内科杂志,2013,52(1):76-82.
[7] 向伟,王禹川,刘芳,等.CHADS2评分与CHA2DS2-VASc评分优劣性比较[J].中华心血管病杂志,2014,42(5):389-391.
[8] Rosendaal F R,Cannegieter S C,van der Meer F J,et al.A method to determine the optimal intensity of oral anticoagulant therapy[J].Thromb Haemost,1993,69(3):236-239.
[9] Chan P H,Hai J J,Chan E W,et al.Use of the SAMe-TT2R2 Score to predict good anticoagulation control with warfarin in Chinese patients with atrial fibrillation:relationship to ischemic stroke incidence[J].PLoS One,2016,11(3):e150674.
[10] Oldgren J,Healey J S,Ezekowitz M,et al.Variations in cause and management of atrial fibrillation in a prospective registry of 15,400 emergency department patients in 46 countries:the RE-LY Atrial Fibrillation Registry[J].Circulation,2014,129(15):1568-1576.
[11] 孙艺红,胡大一.非瓣膜病心房颤动患者全球抗凝注册研究中国亚组基线数据分析[J].中华心血管病杂志,2014,42(10):846-850.
[12] Apostolakis S,Sullivan R M,Olshansky B,et al.Factors affecting quality of anticoagulation control among patients with atrial fibrillation on warfarin:the SAMe-TT(2)R(2) score[J].Chest,2013,144(5):1555-1563.
[13] 刘晓燕,郭晴晴,张群.瓣膜术后口服华法林患者的延续护理[J].护理学杂志,2017,32(22):93-96.
[14] Ruff C T,Giugliano R P,Braunwald E,et al.Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation:a meta-analysis of randomised trials[J].Lancet,2014,383(9921):955-962.
[15] Macedo A F,Bell J,Mccarron C,et al.Determinants of oral anticoagulation control in new warfarin patients:analysis using data from Clinical Practice Research Data-link[J].Thrombosis Research,2015,136(2):250-260.
[16] 夏沪露,张晓艳,蒋凌燕,等.回馈教学在华法林治疗房颤患者健康教育中的应用[J].护理学杂志,2017,32(13):21-23.
[17] Nathisuwan S,Dilokthornsakul P,Chaiyakunapruk N,et al.Assessing evidence of interaction between smoking and warfarin:a systematic review and meta-analysis[J].Chest,2011,139(5):1130-1139.
[18] Vestergaard A S,Skj?th F,Larsen T B,et al.The importance of mean time in therapeutic range for complication rates in warfarin therapy of patients with atrial fibrillation:a systematic review and meta-regression analysis[J].PLoS One,2017,12(11):e0188482.
[19] Veeger N J,Piersma-Wichers M,Tijssen J G,et al.Individual time within target range in patients treated with vitamin K antagonists:main determinant of quality of anticoagulation and predictor of clinical outcome.A retrospective study of 2300 consecutive patients with venous thromboembolism[J].Br J Haematol,2005,128(4):513-519.
[20] Heneghan C,Ward A,Perera R,et al.Self-monitoring of oral anticoagulation:systematic review and meta-analysis of individual patient data[J].Lancet,2012,379(9813):322-334.
[21] Holbrook A,Schulman S,Witt D M,et al.Evidence-based management of anticoagulant therapy:Antithrombotic Therapy and Prevention of Thrombosis,9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J].Chest,2012,141(2 Suppl):e152S-e184S.