华法林抗凝治疗非瓣膜性心房颤动临床应用效果观察

目的:探讨华法林抗凝治疗应用于非瓣膜性心房颤动的效果.方法:选择非瓣膜性心房颤动患者140例,采用随机的方法分为观察组和对照组,每组70例.观察组采用口服华法林抗凝治疗,对照组采用口服阿司匹林抗血小板治疗,观察两组的临床治疗效果及发生栓塞和出血的情况.结果:观察组患者治疗总有效率(95.7%)显著高于对照组(57.1%),且观察组患者发生脑栓塞、脑出血和其他部位出血的发生几率均低于对照组,分别比较差异显著(P<0.05).结论:华法林抗凝治疗非瓣膜性心房颤动,可明显缓解其心房颤动,降低不良事件发生率,疗效确切,值得临床推广应用.     

华法林预防瓣膜病伴心房颤动患者血栓栓塞的临床观察

目的观察华法林对瓣膜病伴心房颤动（房颤）患者血栓栓塞发生的预防和安全性。方法将确诊为二尖瓣狭窄伴房颤患者197例分为华法林抗凝和阿司匹林抗血小板治疗两组，观察两组血栓栓塞并发症及出血等不良反应的发生率。结果华法林组血栓栓塞年发生率为0．55％，阿斯匹林组为3．85％，两组比较差异有显著性（P〈0．05），其不良反应为出血倾向及皮疹、消化道反应。结论华法林抗凝强度国际标准化比值（INR）2．0—3．0，较单纯阿斯匹林抗血小板治疗降低瓣膜病伴房颤患者血栓栓塞的发生率有明显优越性，且安全性好。     

高龄房颤患者应用华法林治疗的影响因素与出血风险

目的探讨高龄房颤患者应用华法林治疗的影响因素与出血风险。方法该院收治的高龄房颤患者55例,根据患者的年龄将患者分为70～79岁组11例,80～89岁组35例,90岁以上组9例。所有患者均给予控制心律、抗血小板以及抗凝药物治疗。结果 55例患者中,共有38例患者接受抗血小板治疗,全部患者均接受华法林抗凝治疗。所有患者均无深静脉血栓以及心房血栓的发生。随着年龄的增加,患者发生出血事件的机率也随之增加。结论华法林在高龄房颤患者中可以有效的预防血栓的发生,但存在出血风险,需注意患者出血情况,以达到最佳的疗效。     

120例心房颤动住院患者抗栓治疗的临床分析

目的回顾分析心房颤动住院患者抗栓治疗情况,初步探讨心房颤动住院患者的病因组成、抗栓治疗现状。方法选择2008年1月～2009年7月住院的心房颤动患者120例,应用ACC/AHA/ESC心房颤动指南血栓栓塞危险分层标准对患者进行危险评估,对其病因、血栓栓塞危险因素、抗血栓药物应用情况及未应用华法林抗凝治疗原因进行分析。结果房颤的病因以冠心病、高血压病、老年退行性心瓣膜病、风湿性心瓣膜病及肺心病为主。对120例患者进行血栓栓塞危险评估,绝大多数合并多种危险因素,符合抗凝指征的患者82例,其中应用华法林者只有18例(21.9%),应用阿司匹林者35例(42.7%),其他抗血小板药物21例(25.6%),未应用抗血栓药物8例(9.7%)。结论冠心病、高血压病、老年退行性心脏瓣膜病等是房颤的主要病因。房颤患者华法林应用率低,依从性差,抗血小板药使用率高,患者抗栓治疗欠规范,需加强医生和患者抗栓治疗重要性和必要性的教育。     

双重抗血小板与华法林预防高危非瓣膜性心房颤动患者血栓栓塞的对照研究

目的 比较阿司匹林联合双嘧达莫与华法林预防高危非瓣膜性心房颤动(NVAF)患者血栓栓塞的有效性和安全性.方法 将确诊的140例高危NVAF患者,采用机械抽样法随机分为两组,分别给予调整剂量华法林抗凝治疗[华法林组78例,目标国际标准化比值(INR)为2.0～3.0,年龄>75岁者INR为1.6～2.5]和阿司匹林联合双嘧达莫治疗(联合治疗组62例,阿司匹林100mg1次/d+双嘧达莫100 mg 3次/d).观察两组患者死亡、血栓栓塞事件(缺血性脑卒中和周围动脉栓塞)及各种出血的发生率.结果 随访12～28个月.华法林组失访3例,发生缺血性脑卒中2例,严重出血2例,轻微出血6例;联合治疗组失访2例,发生缺血性脑卒中6例,周围动脉栓塞2例,轻微出血3例,无严重出血病例.华法林组血栓栓塞事件的发生率明显低于联合治疗组[2.7%(2/75)比13.3%(8/60),P<0.05];出血发生率高于联合治疗组,但差异无统计学意义[10.7%(8/75)比5.0%(3/60),P>0.05].结论 华法林抗凝治疗预防高危NVAF患者血栓栓塞事件的疗效优于阿司匹林联合双嘧达莫抗血小板治疗,当INR>3.0时出血发生率明显增加,严密监测下(INR 2.0～3.0)调整剂量华法林抗凝治疗安全有效.     

华法林与阿司匹林在脑卒中二级预防中房颤的疗效分析

目的探讨华法林与阿司匹林在脑卒中二级预防中房颤的·临床疗效。方法选择我院70例老年房颤患者,其中男性患者48例,女性患者22例,随机分为治疗组和对照组,每组55例,各组均常规给予病因治疗,合理控制血糖、血压、血脂、心室率等,对照组常规口服阿司匹林100mg,1次／日。治疗组化验凝血四项后开始口服华法林,2．5mg／日,定期监测INR调整华法林用量,调整INR在2．0-2．5。对比两组患者服用华法林和阿斯匹林等抗血栓药物后,3年内脑栓塞、脑出血等疾病的发生率。结果对照组55例中脑栓塞11例（31．4％）,脑出血2例（5．7％）,治疗组55例中脑栓塞1例（2．9％）,脑出血2例（5．7％）。脑栓塞发病率治疗组较对照组显著下降（P〈0．05）,脑出血发病率治疗组较对照组无统计学差距（P〉0．05）。结论口服华法林对房颤病人发生脑栓塞的预防疗效明显,不增加脑出血的发生率。     

120例心房颤动住院患者抗栓治疗的临床分析

目的回顾分析心房颤动住院患者抗栓治疗情况,初步探讨心房颤动住院患者的病因组成、抗栓治疗现状。方法选择2008年1月～2009年7月住院的心房颤动患者120例．应用Acc／AHA／Esc心房颤动指南血栓栓塞危险分层标准对患者进行危险评估,对其病因、血栓栓塞危险因素、抗血栓药物应用情况及未应用华法林抗凝治疗原因进行分析。结果房颤的病因以冠心病、高血压病、老年退行性心瓣膜病、风湿性心瓣膜病及肺心病为主。对120例患者进行血栓栓塞危险评估,绝大多数合并多种危险因素,符合抗凝指征的患者82例,其中应用华法林者只有18例（21．9％）,应用阿司匹林者35例（42．7％）,其他抗血小板药物21例（25．6％）,未应用抗血栓药物8例（9．7％）。结论冠心病、高血压病、老年退行性心脏瓣膜病等是房颤的主要病因。房颤患者华法林应用率低,依从性差,抗血小板药使用率高,患者抗栓治疗欠规范,需加强医生和患者抗栓治疗重要性和必要性的教育。     

心房颤动患者华法林和华法林加用阿司匹林的治疗及安全性比较

目的观察华法林和华法林加用阿司匹林对房颤患者预防血栓栓塞的疗效。方法选择房颤患者共148例,随机分成两组：A组83例,给予华法林口服;B组65例,阿司匹林及华法林口服,两组患者均予以监测INK,INK在2．0—3．0之间,两组患者性别、年龄、心功能、肝肾功能、凝血功能及血清电解质差异无统计学意义。疗效观察：（1）两组患者缺血性卒中、心肌梗死及周围动脉栓塞等血管事件的发生率、病死率;（2）出血并发症（胃肠道出血,血尿。症状性脑出血）的发生率。结果两组患者缺血性脑卒中及周围动脉栓塞的发生率因栓塞而再入院例数无明显差异。加用阿司匹林组出血并发症发生率高。结论加用阿司匹林对房颤病人预防血栓栓塞与单用华法林效果相当．但出血风险明显增加．     

抗凝剂与抗血小板剂预防老年非瓣膜病性心房颤动患者缺血性卒中的对比研究

目的 对比抗凝剂与抗血小板剂预防老年非瓣膜病性心房颤动患者缺血性卒中的疗效及安全性.方法 将符合研究条件的老年非瓣膜病性心房颤动患者(年龄≥60岁)186例随机分为抗凝组、抗血小板组和联合组,每组62例.抗凝组采用华法林治疗,起始剂量2.5 mg/d,根据国际标准化比值(INR)调整剂量;抗血小板组采用阿司匹林治疗,剂量100 mg/d;联合组联合采用华法林和阿司匹林.主要终点指标是出现缺血性卒中、严重出血、动脉栓塞表现.比较三组患者的缺血性卒中发生率、症状及体征,同时监测血流动力学及不良反应情况.结果 抗凝组发生缺血性卒中3例(4.84%),抗血小板组11例(17.74%),联合组2例(3.23%),抗凝组与抗血小板组比较差异有统计学意义(P<0.05);联合组与抗凝组比较差异无统计学意义(P>0.05).三组在血流动力学及缺血性卒中症状、体征方面比较,差异无统计学意义(P>0.05).抗凝组与抗血小板组无严重并发症发生,联合组出现2例消化道出血,三组并发症发生率比较,差异无统计学意义(P>0.05).结论 在老年非瓣膜病性心房颤动患者缺血性卒中预防中,抗凝治疗优于抗血小板治疗,而且较安全.     

老年心房纤颤患者不同抗栓治疗方案的临床观察

目的观察老年心房纤颤(房颤)患者使用口服抗凝药进行抗栓治疗的临床效果。方法选择2010—2011年年龄大于75岁持续性房颤患者232例。依据CHA2DS2系统评分大于2分栓塞风险较高,建议口服抗凝药抗栓治疗,HAS-BLED评分系统大于3分相对出血风险较高,需综合评估风险与收益选择治疗方案。根据不同的抗栓治疗方案将所有病例(232例)随机分为华法林组(95例)、阿司匹林组(103例)与氯吡格雷组(39例)。记录所有患者基本临床资料(性别、年龄、高血压病史、糖尿病史、卒中史、冠心病史等),观察各组间基本资料分布情况和口服药物6个月内定期随访患者不良事件的发生情况。结果在华法林组有高血压59例(62.1%),阿司匹林组75例(72.8%),高于氯吡格雷组7例(20.6%),经比较,差异有统计学意义(P0.01);其他基本临床资料3组间差异无统计学意义。华法林组CHAD2S2-VASc评分明显高于阿司匹林组和氯吡格雷组,差异有统计学意义(4.2±1.1 vs 3.9±0.9,3.6±0.7,P0.05);栓塞发生率氯吡格雷组4例(11.8)、阿司匹林组9例(8.7),与华法林组1例(1.1%)比较,差异有统计学意义(P0.05)。3组间HAS-BLE评分、轻微出血、大出血比较,差异无统计学意义。3组均无死亡病例。结论对于栓塞及出血风险均相对较高的老年房颤患者,使用口服抗凝药将国际标准化比值(INR)控制在2.0～3.0之间可明显降低栓塞发生率,并未明显增加出血风险。     

Atrial Fibrillation in Long Term Care

Increasing age is a potent risk factor for the development of atrial fibrillation (AF), as well as for incident stroke in patients with AF. The prevalence of AF in long term care facilities ranges from 7.5% to 17%, and such patients often present management challenges due to heightened risk for both stroke and bleeding complications related to thromboprophylaxis. This article reviews the diagnosis and management of AF in long term care. In general, patients with minimal symptoms can be managed with rate-control medications and anticoagulation. Patients with persistent symptoms and impaired quality of life despite adequate rate-control should be considered for cardioversion and antiarrhythmic drug therapy aimed at maintaining sinus rhythm. A small percentage of patients who do not respond to rate-control or rhythm-control interventions may be candidates for a catheter-based or surgical ablative procedure. In most older adults, the benefits of systemic anticoagulation in reducing the risk of stroke outweigh the risk of serious bleeding; therefore, anticoagulation is indicated in the majority of older AF patients, including nursing home residents. Although warfarin remains the preferred agent for stroke prophylaxis in the long term care setting, primarily due to very limited experience with the newer agents dabigatran, rivaroxaban, and apixaban, it is likely that the use of these newer drugs will increase as additional data accumulate documenting their safety and efficacy in AF patients of advanced age.     

疾病管理提高房颤患者抗凝治疗依从性及效果的评价

目的探讨在房颤患者中进行疾病管理对其抗凝治疗的依从性及治疗效果的影响。方法项目从2009年1月开始,以2009年l-4月住院采取抗凝治疗的110例房颤患者作为疾病管理组。疾病管理方法包括住院期间医生或护士进行常规抗凝治疗教育,提供健康教育手册。出院后每月1次电话随访,指导药物剂量的调整并进行监测。对照组为2008年6-12月住院采取抗凝治疗的房颤患者,仅在住院期间接受医生或护士的常规教育。出院1年时了解两组患者抗凝治疗的情况。结果两组患者性别、年龄、房颤病程和脑卒中高危患者的构成差异无统计学意义。出院1年时疾病管理组抗凝治疗的依从率为85．5％,对照组为53．1％,差异有统计学意义（X^2=30．43,P〈0．001）;疾病管理组监测的依从性显著高于对照组（81.8％US．65．9％,P=0．014）;疾病管理组抗凝治疗的达标率（INR：2．0～3．0）高于对照组（65．9％,US．43．5％,P=0．002）;疾病管理组抗凝治疗相关知识知晓率均高于对照组（P〈0．05）;接受疾病管理的患者对疾病管理的总体满意度达93．6％,电话随访指导方式的满意度达91．8％。结论在房颤患者中进行疾病管理可显著提高抗凝治疗相关知识的知晓率、抗凝治疗和监测的依从性及治疗的达标率,电话随访是患者满意的疾病管理方式。     

Incidence of chronic atrial fibrillation in general practice and its treatment pattern

The object of this article was to estimate the incidence rate of chronic atrial fibrillation (AF) in a general practice setting, to identify factors predisposing to its occurrence, and to describe treatment patterns in the year following the diagnosis. The method used was a population-based cohort study using the General Practice Research Database (GPRD) in the UK. We identified patients aged 40-89 years with a first ever recorded diagnosis of AF. The diagnosis was validated through a questionnaire sent to the general practitioners. A nested case-control analysis was performed to assess risk factors for AF using 1,035 confirmed incident cases of chronic AF and a random sample of 5,000 controls from the original source population. The incidence rate of chronic AF was 1.7 per 1,000 person-years, and increased markedly with age. The age adjusted rate ratio among males was 1.4 (95% CI 1.2-1.6). The major risk factors were age, high BMI, excessive alcohol consumption, and prior cardiovascular comorbidity, in particular, valvular heart disease and heart failure. Digoxin was used in close to 70% of the patients, and close to 15% did not receive any antiarrhythmic treatment. Close to 40% did not receive either warfarin or aspirin in the 3 months period after the diagnosis. Among the potential candidates for anticoagulation only 22% of those aged 70 years or older were prescribed warfarin in comparison to 49% among patients aged 40-69 years. Chronic AF is a disease of the elderly, with women presenting a lower incidence rate than men specially in young age. Age, weight, excessive alcohol consumption, and cardiovascular morbidity were the main independent risk factors for AF. Less than half of patients with chronic AF and no contraindications for anticoagulation received warfarin within the first trimester after the diagnosis.     

Are atrial fibrillation guidelines altering management? A community based study

BACKGROUND AND AIMS: We wanted to determine the prevalence of atrial fibrillation (AF) in a community based cross sectional study in greater Glasgow and how current anti-thrombotic management compares to published guidelines. METHODS: 1466 patients with AF were identified in General Practices in our community and 1008 consented to take part. Their demographic details and medical history were recorded. RESULTS: 1466 patients (mean age 73.4; 55% female) with AF were identified, in our community, giving a prevalence of 1%. 53% of patients were on warfarin therapy. Of those not receiving warfarin, only one third had a putative contra-indication. The proportion ofAF patients on warfarin increased with increasing stroke risk, and over the period of the study. CONCLUSIONS: Prevalence of AF was in keeping with previous estimates. The proportion of patients with AF receiving warfarin therapy appears to be increasing. In the moderate risk group, there was a tendency to use more warfarin in the younger age groups compared to the elderly. It was in the moderate and low risk groups that there was still evidence of deviation from published guidelines.     

Which acute stroke patients with atrial fibrillation are prescribed warfarin therapy? Results from one-year's experience in Dundee

The recommended treatment of ischaemic stroke patients with atrial fibrillation (AF) is anticoagulation therapy with warfarin sodium and if this is contraindicated then aspirin should be used. The management of patients on warfarin therapy can be complicated and there is a risk of intra-cranial haemorrhage in elderly patients. However, these are the patients who stand to gain the most benefit from this treatment and therefore increased use of warfarin for secondary prophylaxis is likely to lead to a lower rate of subsequent admissions and less morbidity. The recommended treatment for these patients has often not been fully instigated in practice. This study was carried out in order to determine whether a group of patients admitted to a teaching hospital with diagnosis of ischaemic stroke and atrial fibrillation received appropriate antithrombotic therapy. Details of patients admitted with acute stroke during 1997 were obtained from the Dundee Stroke Database and information was extracted from the relevant clinical notes. Twenty-five out of 42 patients (60%) were considered eligible for anticoagulation and 14 out of those 25 (56%) were found to be on warfarin either on admission or subsequently. Of patients aged less than 75 years, 8/10 (80%) were on warfarin, whereas only 6/15 (40%) of those aged 75 years and older were being anticoagulated.     

Socioeconomic Implications of Long-Term Warfarin Use

Current guidelines recommend the use of warfarin in all patients with atrial fibrillation (AF) and/or an artificial heart valve who are at high risk of thromboembolism. While anticoagulation with warfarin greatly reduces this risk, a careful system of monitoring and management is necessary to maintain a therapeutic dose and minimize adverse events. This rigorous process places a burden on providers, and many patients managed in typical office practices are not optimally anticoagulated.To improve the quality and efficiency of anticoagulation and remove its burden from office-based physicians, newer treatment models have evolved, including anticoagulation clinics and self-monitoring by patients at home. While these newer models often incorporate innovative programs to streamline warfarin management, little is known about their individual or relative economic merits or those of traditional office-based care. The routine costs of anticoagulation within any model have not been well documented. The cost of warfarin is readily available; however, attendant expenses, such as dose adjustment, laboratory testing, and medical encounters, are difficult to gauge. Because of these challenges in collecting practice data, most estimates of the cost of anticoagulation services have relied upon assumptions about practice patterns. Assessing the cost of anticoagulation is easier in a clinic setting because all costs relate exclusively to anticoagulation. A recent study of anticoagulation clinics estimated that annual direct costs per patient for anticoagulation services totaled approximately $US280–$US380 (2002 values). Bleeding and other complications experienced by anticoagulated patients add additional types of costs, with inpatient care accounting for more than one-half of the total cost of managing excessive anticoagulation. When quality of life is considered alongside costs to gauge the cost effectiveness of warfarin therapy versus aspirin (acetylsalicylic acid), warfarin appears to be cost-saving in patients at high stroke risk and cost effective in those at moderate risk. For patients at lower risk of stroke, aspirin is more cost effective than warfarin.With the aging of the population and consequent increases in patient groups requiring anticoagulation, the US healthcare system greatly needs improvements to anticoagulation management. New research must determine which models of management will provide the most favorable outcomes for high-risk patients at the lowest cost to payors and society.     

达比加群酯治疗ACS心房颤动的研究进展

我国流行病学调查显示,35岁及以上人群心房颤动加权患病率为0.71%,随年龄增长患病率明显增高,房颤人群的脑卒中风险明显高于非房颤人群,房颤的疾病负担是一个重要的公共卫生问题,而抗凝治疗能够降低房颤患者的血栓栓塞风险。达比加群酯作为新型口服抗凝药目前在临床上得到了应用。其口服后经胃肠吸收,在体内转化为有抗凝活性的达比加群,直接抑制凝血酶,阻止纤维蛋白原转化为纤维蛋白,从而抑制血栓形成。在非瓣膜病性心房颤动患者中,国内外研究均显示了达比加群酯与华法林比较,预防血栓栓塞不差于华法林,且出血性并发症、不良反应均低于华法林,对于老年房颤患者同样安全、有效。而且,依达赛珠单抗能够有效地逆转达比加群的抗凝作用,也提高了其的使用安全性。目前在急性冠脉综合征(ACS)心房颤动患者中使用达比加群酯的研究尚未显示出其绝对优势,现就近年来关于这方面的研究做一综述,为临床应用提供可参考依据。     

华法林抗凝治疗非瓣膜病房颤的研究

目的华法林抗凝治疗非瓣膜病性心房颤动（AF）患者的抗栓疗效和出血危险性。方法140例非瓣膜病性AF患者分为两组：治疗组74例,服用华法林服用从1．5mg开始,1次／d,根据血浆凝血酶原时间国际标准化比率（INR）调整华法林剂量,INK达标为2．0—3．0,持续服药,并随访1年;对照组66例,持续服安慰剂,并随访1年。观察两组栓塞事件及出血发生率。结果治疗组栓塞事件及出血发生率分剐为o％和2．7％,对照组栓塞事件及出血发生率分别为4．5％和0％。两组比较差畀均有统计学意义（P〈0．01）。结论华法林抗凝治疗非瓣膜病性AF患者,华法林抗凝目标INK值在2。0—3．0是安全有效。