衰弱对于老年心房颤动患者抗凝决策的影响

心房颤动(简称房颤)是老年患者最常见的心律失常,房颤患者的衰弱率随着年龄增长而增加,表现为躯体储备功能下降和并发症增加,影响抗凝治疗的安全性。老年房颤患者栓塞风险较高,除了进行栓塞评分外,还应进行衰弱评估,个体化地选择抗凝方案。衰弱的老年房颤患者不应拒绝抗凝治疗,使用新型口服抗凝药物会有更多获益。本文就衰弱对老年房颤患者的抗凝决策进行论述。     

老年心房颤动患者的抗凝策略与抗凝强度评价

房颤是一个严重的临床问题,随着年龄增长,其发病率逐渐增高。房颤所导致的血栓栓塞并发症高,致死、致残率高,未经治疗的房颤患者脑卒中年发生率平均为5%。在临床工作中,年龄是房颤患者血栓栓塞危险分层及指导抗凝策略的重要因素,对75岁以上、肾功能异常、高血压未能良好控制者在抗凝治疗中应加强监测,可考虑适当降低抗凝强度,以防止出血并发症。     

Stroke prevention in elderly patients with atrial fibrillation: challenges for anticoagulation

Elderly patients with atrial fibrillation (AF), who constitute almost half of all AF patients, are at increased risk of stroke. Anticoagulant therapies, especially vitamin K antagonists (VKA), reduce the risk of stroke in all patients including the elderly but are frequently under-used in older patients. Failure to initiate VKA in elderly AF patients is related to a number of factors, including the limitations of current therapies and the increased risk for major haemorrhage associated with advanced age and anticoagulation therapy. Of particular concern is the risk of intracranial haemorrhages (ICH), which is associated with high rates of mortality and morbidity. Novel oral anticoagulant agents that are easier to use and might offer similar or better levels of stroke prevention with a similar or reduced risk of bleeding should increase the use of antithrombotic therapy in the management of elderly AF patients. Amongst these new agents, the recently approved direct thrombin inhibitor dabigatran provides effective stroke prevention with a significant reduction of ICH, and enables clinicians to tailor the dose according to age and haemorrhagic risk.     

Left atrial thrombus and prognosis after anticoagulation therapy in patients with atrial fibrillation

Background

Anticoagulation therapy reduces the risk of thromboembolic events by two-thirds in patients with atrial fibrillation (AF). The prevalence of left atrial thrombus (LAT) in AF patients with anticoagulation therapy has not been fully investigated.

Purpose

To investigate the prevalence of LAT and its impact on the outcomes in patients with nonvalvular AF after anticoagulation therapy.

Methods

This study consisted of 231 patients with nonvalvular AF who had transthoracic (TTE) and transesophageal echocardiographic (TEE) examinations more than 3 weeks after anticoagulation therapy. The clinical and echocardiographic characteristics were evaluated.

Results

LAT was observed in 13 (8.8%) of 148 patients with sub-therapeutic anticoagulation, and in 3 (3.6%) of 83 patients with sufficient anticoagulation. The presence of LAT was associated with higher CHADS₂ score, decreased LA volume changes and the presence of spontaneous echocardiographic contrast (SEC) in patients with sub-therapeutic anticoagulation. Patients with LAT after sufficient anticoagulation were male with permanent AF who had decreased left ventricular systolic and diastolic function and dilated LA on TTE and SEC, and reduced appendage flow velocity on TEE. Patients with LAT had worse cardiovascular outcomes compared with those without LAT (p = 0.02).

Conclusions

We demonstrated that LAT was a univariate risk factor associated with worse cardiovascular outcomes, which was observed in 8.8% of patients with sub-therapeutic anticoagulation and 3.6% of patients with sufficient anticoagulation.     

Masked thyroid dysfunction among elderly patients with atrial fibrillation

Seventy-five elderly patients with atrial fibrillation (41 males and 34 females with a mean age of 75.6 years) were studied to evaluate the incidence of masked thyroid dysfunction. A thyrotropin (TSH)-releasing-hormone (TRH) test (intravenous injection of 250 micrograms of synthetic TRH) was performed in the patients and 30 age matched controls without atrial fibrillation. In the controls, no abnormal TRH stimulated TSH response was observed. In the patients with atrial fibrillation, no response of TSH to TRH (hyperthyroidism) was found in 5 cases (6.6%), while hyperresponse of TSH to TRH (hypothyroidism) was found in 6 cases (8.0%). Thyroid dysfunction (hyper or hypothyroidism) was more frequently observed in the patients than in the controls (p less than 0.05). Two of 5 hyperthyroid patients had normal thyroid hormone levels. All patients with hyperthyroidism were treated with antithyroid drugs or 131I. Unfortunately, atrial fibrillation persisted in all but 1 case. It is concluded that the TRH test is a useful screening test for detecting those patients with abnormal thyroid function among elderly patients with atrial fibrillation, and that hypothyroidism should be considered as a cause of atrial fibrillation in the elderly.     

老年非瓣膜性心房颤动抗凝治疗现状分析

目的分析影响老年非瓣膜性心房颤动患者抗凝治疗的因素,为提高老年心房颤动患者抗凝治疗寻求解决方法。方法对2009-10-01—2010-04-30入住北京协和医院,年龄≥65岁的老年非瓣膜性心房颤动患者进行门诊及电话随访,观察分析全因死亡、抗凝比例、未选择抗凝的原因、抗凝终止的原因、不抗凝(抗凝终止)后的抗栓方法等指标。结果共70例连续入院的患者纳入研究,平均随访9.1个月(6.0~13.5个月)。有效随访63例,其中包括年龄<75岁组33例和年龄≥75岁组30例。失访7例(10%)。随访期间共8例(12.7%)死亡,包括年龄<75岁组1例(3%)和年龄≥75岁组7例(23.3%)。有效随访病例中,进行抗凝治疗的仅16例(25.4%),这16例中INR达标13例。8例死亡患者均未进行抗凝治疗,其中6例称大夫未交待抗凝,另2例有明确抗凝禁忌证。结论老年心房颤动患者抗凝比例低,有效抗凝率低。抗凝过程中中断的比例高。解决老年心房颤动患者抗凝过程的具体困难是有效治疗的关键。     

Atrial fibrillation, anticoagulation, fall risk, and outcomes in elderly patients

Atrial fibrillation (AF) affects 2.5 million patients in the United States. The incidence of this condition increases with age, such that approximately 5% of people > 65 years of age have AF. Because of the lack of organized atrial contraction and thrombus formation in the left atrium, patients with AF are at increased risk of stroke. The estimated risk of stroke among all AF patients is 5% per year. Among patients without mitral stenosis, there is a graded relationship of stroke risk with the number of CHADS? risk factors. Warfarin is the recommended treatment for embolic stroke prophylaxis in AF in intermediate- to high-risk patients. However, elderly patients who are deemed to be at risk of falls are often not started on warfarin therapy secondary to a perceived higher risk of bleeding complications. These risks have been evaluated, but conclusive data regarding the risk-benefit trade-off are elusive. This review summarizes available data on the use of warfarin in elderly patients with AF, focusing on the risk of bleeding, and will specifically address the utility of falls risk assessment in the decision to initiate warfarin therapy for AF.     

非瓣膜性心房颤动患者围术期的抗凝治疗

大多数非瓣膜性心房颤动(NVAF)患者需长期应用口服抗凝药物,以减少中风及系统性栓塞的风险。这些患者在接受外科手术或侵入性操作时出血风险增加,部分患者在围术期需暂时中断抗凝治疗。近年来,对于NVAF患者围术期暂时中断抗凝治疗的适应症、时间、暂时中断口服抗凝药物后抗凝治疗的桥接,以及术后抗凝治疗的重新应用已有较多的临床研究。本文简要介绍NVAF患者围术期抗凝治疗的研究现状。     

Oral anticoagulation in patients with atrial fibrillation: adherence with guidelines in an elderly cohort

PURPOSE: To determine adherence with practice guidelines in a population-based cohort of elderly persons aged 70 years or older with atrial fibrillation. SUBJECTS AND METHODS: This was a cross-sectional analysis of a subgroup of participants in the Cardiovascular Health Study, a prospective observational study involving four communities in the United States. Subjects were participants with atrial fibrillation on electrocardiogram at one or more yearly examinations from 1993 to 1995. The outcome measure was self-reported use of warfarin in 1995. RESULTS: In 1995, 172 (4.1%) participants had atrial fibrillation together with information regarding warfarin use and no preexisting indication for its use. Warfarin was used by 63 (37%) of these participants. Of the 109 participants not reporting warfarin use, 92 (84%) had at least one of the clinical risk factors (aside from age) associated with stroke in patients with atrial fibrillation. Among participants not taking warfarin, 47% were taking aspirin. Several characteristics were independently associated with warfarin use, including age [odds ratio (OR) = 0.6 per 5-year increment, 95% CI 0.5-0.9], a modified mini-mental examination score <85 points [OR = 0.3, 95% confidence interval (CI) 0.1-0.9], and among patients without prior stroke, female sex (OR = 0.5, 95% CI 0.2-1.0). CONCLUSIONS: Despite widely publicized practice guidelines to treat patients who have atrial fibrillation with warfarin, most participants who had atrial fibrillation were at high risk for stroke but were not treated with warfarin. More studies are needed to determine why elderly patients with atrial fibrillation are not being treated with warfarin.     

Current status of anticoagulation therapy for elderly atrial fibrillation patients in Japan: from Hokuriku atrial fibrillation trial

BACKGROUND: The number of the elderly patients with atrial fibrillation (AF) is increasing, but the current status of anticoagulation therapy for elderly patients with AF in Japan is not clear. METHODS AND RESULTS: Among the patients registered in the "Hokuriku Atrial Fibrillation Trial (HAT) 1", 365 AF patients aged > or =65 years were enrolled in this study. Warfarin was used for significantly less patients in the oldest group aged > or =85 years (36%) than in younger populations, but the percentage of antiplatelet use in this oldest population was largest (40%). The elderly group (> or =85 years) was compared with a younger group aged between 75 and 84 years. Warfarin was given to 61% of the younger group compared with 36% in the elderly group. In the younger group, the more thromboembolic risks they had according to CHADS2 score, the more warfarin was used, whereas there was no clear trend in the usage of warfarin in the elderly group. CONCLUSIONS: The number of elderly Japanese patients with AF taking warfarin is currently low, but because the population of elderly AF patients will increase in the future, there is a need for safe and suitable anticoagulation therapy for elderly patients.     

关注高龄心房颤动患者的抗凝治疗

心房颤动（房颤）显著增加卒中风险,抗凝治疗是房颤综合管理的重要组成部分。我国房颤患者抗凝比例仍然很低,尤其是高龄老年人。该文在新近发表文献的基础上,重点阐述了包括超高龄在内的高龄房颤患者抗凝治疗的净获益;同时强调了与相对年轻的房颤患者相比,非维生素K拮抗剂口服抗凝药在高龄非瓣膜性房颤患者抗凝中同样具有优势;抗血小板治疗...     

高龄稳定性冠心病合并心房颤动患者不同强度华法林抗凝治疗研究

目的观察不同强度华法林抗凝治疗对高龄稳定性冠心病合并非瓣膜性心房颤动患者的疗效和安全性。方法选择高龄稳定性冠心病合并非瓣膜性心房颤动患者91例,随机分为低强度组45例,华法林初始量为1.25mg/d,如国际标准化比值(INR)1.4,3~5d加0.5~1.0mg/d,INR维持1.4~2.0;中强度组46例,INR维持2.0~2.6。平均随访2年,比较2组主要终点(缺血性脑卒中、体循环栓塞)和次要终点(非致命性心肌梗死、全因死亡联合终点)及安全性终点(致命性出血、严重出血和轻度出血)。结果与中强度组比较,低强度组INR明显降低(1.70±0.36 vs 2.35±0.37,P=0.034),华法林用量明显减少[(2.70±0.30)mg/d vs(3.50±0.35)mg/d,P=0.040]。中强度组安全性终点中的总出血事件比例明显高于低强度组(17.4%vs 4.4%,P=0.040)。结论高龄稳定性冠心病合并非瓣膜性心房颤动患者,华法林低强度与中强度抗凝治疗比较,预防缺血性心脑血管事件终点相似,但安全性甚好。     

高龄非瓣膜病性房颤患者长期应用华法林抗凝治疗的疗效与安全性

目的观察高龄非瓣膜病性房颤(NVAF)患者长期应用华法林抗凝治疗的疗效及安全性。方法入选NVAF患者按年龄分为3组,高龄老年组55例,年龄≥80岁(INR在1.6~2.5之间);老年组45例,年龄65~79岁(INR在l.6~2.5之间);中年组37例,年龄65岁(INR在2.0~3.0)。入选患者长期服用华法林抗凝治疗,根据INR测定值及其变化趋势来调整华法林剂量,使INR达标,比较3组患者口服华法林5年时的不良反应及华法林的安全用药范围及国际标准化比值(INR)。结果 5年随访期间,三组患者均未发生缺血性卒中,三组患者出血及其他不良反应无统计学差异(P0.05)。随访第5年时,高龄老年组华法林组剂量(2.89±0.52)mg,INR(2.15±0.31),老年华法林组剂量(2.99±0.41)mg,INR(2.21±0.30),差异无统计学意义(P0.05)。中年组华法林剂量(3.39±0.61)mg,INR(2.55±0.60),华法林剂量及INR明显高于高龄老年组和老年组,差异有统计学意义(P0.05)。结论严密监测INR下,对于高龄老年NVAF患者应用华法林抗凝治疗,INR控制在1.5~2.5安全有效。     

Hospitalization affects the anticoagulation patterns of patients with atrial fibrillation

Journal of Thrombosis and Thrombolysis - Scarce data are available on the effects of hospitalization on oral anticoagulation (OAC) patterns in patients with atrial fibrillation (AF). This study...     

高龄心房颤动患者导管消融治疗围术期抗凝方案的研究

目的 探讨高龄心房颤动(房颤)患者行导管消融治疗围术期有效而安全的抗凝方案.方法 选取射频消融治疗的高龄(＞75岁)房颤患者15例(高龄组),术前服用华法林;同期＜75岁射频消融治疗房颤患者15例(非高龄组),根据栓塞风险服用华法林或阿司匹林治疗.术中均用肝素抗凝;高龄组术后以低分子肝素过渡,第3天开始服用华法林,非高龄组术后从第1天开始华法林与低分子肝素重叠应用3d;院外两组服用华法林抗凝3个月.3个月后根据CHADS2评分服用阿司匹林或华法林治疗.门诊随访至少12个月,比较两组凝血酶原时间-国际标准化比值(PT-INR)、6个月内出血和栓塞事件发生率及术后3、6、12个月24 h动态心电图记录心律失常情况.结果 术前高龄组与非高龄组PT-INR值(1.58±0.32对1.37±0.44,P＞0.05),术后INR达标天数[(11.73±3.29)d对(9.71±3.63)d,P＞0.05];左心房内自发显影情况[3例(20.00％)对4例(26.67％),P＞0.05];出血并发症(0对6.67％,P=0.05)、栓塞事件发生率(6.67％对0,P=0.05)差异无统计学意义.两组间术后3、6、12个月心律失常复发情况差异无统计学意义.结论 高龄房颤患者行导管消融治疗术前需严格抗凝并排除心房血栓;术中抗凝与常规用药相同;术后延迟加用华法林治疗同样安全有效.     

Oral anticoagulation and hemorrhagic complications in an elderly population with atrial fibrillation

BACKGROUND: Warfarin sodium therapy in patients with atrial fibrillation markedly reduces the incidence of embolic stroke. However, in elderly patients warfarin therapy is often underused owing to the perceived higher risk of hemorrhagic complications. OBJECTIVES: To assess the quality of anticoagulant control and the incidence of hemorrhagic complications and stroke in an elderly population (>75 years old) compared with a younger control group (between 60 and 69 years) and to assess the quality of anticoagulant control and incidence of hemorrhagic complications in those patients who recently commenced receiving warfarin therapy (first year of therapy). PATIENTS AND METHODS: In this retrospective follow-up study, anticoagulant control and the incidence of hemorrhagic complications and stroke were assessed in an elderly population (>75 years old) compared with a younger control group (between 60 and 69 years), all with atrial fibrillation(target international normalized ratio [INR] 2.5) and attending a hospital outpatient anticoagulant clinic. RESULTS: A total of 328 patients were studied over a 21-month period. There were 204 patients in the control group providing 288 patient-years of follow-up and 124 patients in the elderly group providing 170 patient-years of follow-up. The percentage of INR results in the target range was not statistically significantly different between the elderly and control groups (71.5% vs 66.1%) and the occurrences of incidences of INR greater than 7 were 4.2% in the control group and 4.7% in the elderly group (P =.96). The incidences of major hemorrhage were 2.8% per year in the elderly group and 2.9% per year in the control group (P =.96); overall incidence was 2.8% (95% confidence interval, 1.3%-4.4%). One hundred one of the 328 patients studied commenced warfarin therapy during or within 3 months of the start of the study. In this induction group, 62.1% of INRs were within the target range compared with 70.9% of INRs in patients who had been receiving warfarin therapy for more than 3 months at the start of the study (P =.002). The incidences of INR greater than 7 and major hemorrhage were 7.9% per year and 6.9% per year, respectively, in the cohort who recently began warfarin therapy compared with 3.4% per year and 1.7% per year in the group who were receiving warfarin therapy for more than 3 months. CONCLUSION: While it was impossible to consider any selection bias at the level of referral to the clinic, these findings suggest that the elderly population attending our anticoagulant clinic did not have poorer anticoagulant control or an increased incidence of hemorrhage while receiving warfarin therapy.