心功能对非瓣膜性心房颤动合并冠状动脉支架植入患者缺血性脑卒中及死亡风险的影响

背景　心房颤动（房颤）患者需评估出血/缺血风险进行抗凝治疗，接受冠状动脉支架植入术患者需抗血小板治疗，房颤合并冠状动脉支架植入术患者抗凝加抗血小板则会增加出血风险。心力衰竭（心衰）与房颤常共存且相互作用，在房颤患者中，心衰为脑卒中的公认危险因素。目的　探讨心功能对非瓣膜性房颤合并冠状动脉支架植入术后患者的缺血性脑卒中及死亡风险的影响。方法　收集2010年1月—2015年1月就诊于北京11家三级甲等医院的房颤合并冠状动脉支架植入患者2 471例进行多中心研究。排除失访及瓣膜性房颤患者后实际纳入分析1 987例，平均随访（3.5±1.5）年。根据美国纽约心脏病学会（NYHA）心功能分级进行研究，比较其缺血性脑卒中发生率及死亡率。分别以缺血性脑卒中及死亡为终点事件进行生存分析，绘制Kaplan-Meier生存曲线。同时对出血事件进行分析。最后采用Cox比例风险回归模型对卒中的危险因素进行分析。结果　心功能代偿组1 468例患者，63例发生缺血性脑卒中，占4.29%；心功能失代偿组519例患者，32例发生缺血性脑卒中，占6.17%；两组脑卒中发生率比较，差异无统计学意义（P=0.085）。心功能代偿组有152例死亡，占10.35%，心功能失代偿组有77例死亡，占14.84%，差异有统计学意义（P=0.006）。两组以缺血性脑卒中及死亡为终点事件绘制的生存曲线比较，差异均有统计学意义（P<0.05）。单因素Cox比例风险回归分析显示NYHA分级是缺血性脑卒中发生的影响因素（P=0.047）；进一步纳入传统的卒中危险因素及主要的超声心动图指标的多因素Cox比例风险回归分析结果显示：性别、脑卒中史、NYHA分级、左心室射血分数（LVEF）、左心房内径、左心室舒张末期内径是缺血性脑卒中发生的影响因素（P<0.05）。心功能失代偿组抗凝药物使用比例高于心功能代偿组，差异有统计学意义（P=0.001）。不同心功能分级患者卒中发生率比较，差异无统计学意义（P=0.086），而死亡事件发生率比较差异有统计学意义（P=0.006）。心功能代偿组出血事件占12.74%（187/1 468），心功能失代偿组占11.95%（62/519），差异无统计学意义（P=0.639）。结论　心功能失代偿的冠心病伴非瓣膜性房颤患者有更高的死亡率，随着NYHA分级升高死亡风险亦呈增加趋势。

Effects of Heart Function on Ischemic Stroke and Mortality Risks in Patients with Nonvalvular Atrial Fibrillation and Coronary Artery Stent Implantation

Background　Anticoagulation therapy is often administered to atrial fibrillation（AF） patients whose risk of bleeding with such treatment is outweighed by the benefit of stroke risk reduction.And antiplatelet therapy is often given to those with coronary artery stent implantation （CASI）．However，if giving antithrombotic （anticoagulant and antiplatelet） therapies to AF with CASI patients，their risks of bleeding will be increased.Heart failure commonly coexists and interacts with atrial fibrillation，and it is a recognized risk factor for stroke in AF patients.Objective　To investigate the effect of heart function on the risk of ischemic stroke and death in patients with nonvalvular AF and CASI.Methods　A multicenter study was conducted on 2 471 AF patients with CASI recruited from 11 grade A tertiary hospitals in Beijing from January 2010 to January 2015.After excluding those with valvular AF and those who were lost to follow-up，1 987 patients were finally enrolled.The average follow-up period for them was（3.5±1.5） years.The incidence and mortality of ischemic stroke were compared according to the heart function classification of the New York Heart Association（NYHA）．Survival analysis was carried out with ischemic stroke and death as endpoints，and Kaplan-Meier survival curves were drawn.At the same time，the bleeding events were analyzed.Finally，Cox proportional hazards regression model was used to analyze the risk factors of stroke.Results　The incidence of ischemic stroke was 4.29%（n=63） in compensated heart failure group（n=1 468），and 6.17%（n=32） in decompensated heart failure group（n=519），with no difference（P=0.085）．The mortality rate was 10.35%（n=152） in compensated heart failure group，and 14.84%（n=77） in decompensated heart failure group，showing a significant difference（P=0.006）．There were significant differences in survival curves drawn with ischemic stroke and death as endpoints between the two groups （P<0.05）．Univariate Cox proportional hazards regression analysis showed that NYHA class was associated with the risk of ischemic stroke （P=0.047）．Multivariate Cox proportional hazards regression，which further included traditional risk factors for AF and major echocardiographic indicators，showed that gender，stroke history，NYHA class，left ventricular ejection fraction（LVEF），left atrial diameter，left ventricular end-diastolic diameter were factors associated with ischemic stroke （P<0.05）．The rate of anticoagulants use was higher in decompensated heart failure group than that of compensated heart failure group（P=0.001）．Patients with different NYHA classes showed significantly different mortality rate （P=0.006），but similar stroke incidence（P=0.086）．The incidence of bleeding events was 12.74%（187/1 468） in compensated heart failure group and 11.95%（62/519） in decompensated heart failure group，with no significant difference （P=0.639）．Conclusion　Nonvalvular AF patients with decompensated heart failure have increased risks of death，and the risk of death grows with the deterioration of cardiac function.