心房颤动合并脑栓塞患者的抗凝治疗现状和出血转化分析

目的 通过充血性心力衰竭、高血压、年龄≥75岁（双倍）、糖尿病、卒中（双倍）、血管病变、年 龄65～74岁、女性（Congestive heart failure，Hypertension，Age≥75（doubled），Diabetes Mellitus，Stroke （doubled），vascular disease，age 65～74 and sex category（female），CHA2DS2-VASc）评分观察心房颤 动合并脑栓塞患者的抗栓治疗现状，分析高血压、异常的肝肾功能、卒中、出血、国际标准化比 值（international normalized ratio，INR）不稳定、年龄、药物治疗或者饮酒（Hypertension，Abnormal renal and liver function，Stroke，Bleeding，Labile international normalized ratio，Elderly，Drugs and alcohol intake， HAS-BLED）评分及其他相关临床危险因素与心房颤动合并脑栓塞出血转化的关系。 方法 回顾性分析2012年5月至2014年12月在北京博爱医院神经康复科住院的心房颤动合并脑栓塞 患者的临床资料。根据CHA2DS2-VASc评分观察低危组（0分）、中危组（1分）、高危组（≥2分）的抗栓 治疗情况。根据HAS-BLED评分，分析心房颤动脑栓塞出血转化（hemorrhagic transformation，HT）率在 出血转化低危组（0～2分）和出血转化高危组（≥3分）之间的差异，同时对多个临床变量进行多因素 分析，寻找与HT相关的临床危险因素。 结果 研究共入组101例患者，患者在发生脑栓塞之前，根据CHA2DS2 -VASc评分，低危组抗凝率 66.7%（2/3），无抗血小板治疗；中危组抗凝、抗血小板率均为16.7%（2/12）；高危组抗凝率19.8% （17/86），抗血小板率14.0%（12/86）。脑栓塞前1个月内停用抗凝治疗而发病的占所有抗凝患者 42.8%（9/21）。发生脑栓塞之后，所有患者均为高危组，抗凝治疗率68.3%（69/101），抗血小板 治疗率25.7%（26/101）。根据HAS-BLED评分，心房颤动合并脑栓塞后，出血转化高危组HT 58.5% （31/53），与低危组HT 37.5%（18/48）比较，差异有显著性（χ 2=4.443，P =0.035）。对HT组与非HT 组的多个临床变量分析发现，两组美国国立卫生研究院（National Institutes of Health Stroke Scale， NIHSS）评分差异有显著性（14.860±4.486 vs 11.940±5.648，P =0.006）；HAS-BLED评分差异有显 著性（2.76±0.80 vs 2.21±0.96，P =0.003）；病灶范围大的梗死灶HT为57.9%（44/76），小的梗 死灶为HT 20%（5/25），两组有显著差异（P =0.001）。多因素Logistic回归分析发现NIHSS（OR 1.106， 95%CI 1.106～1.216，P =0.036）、病灶范围大小（OR 5.083，95%CI 1.826～14.148，P =0.002）和HASBLED 评分（OR 2.353，95%CI 1.326～4.175，P =0.003）均是心房颤动患者脑栓塞后HT的危险因素。 结论 心房颤动合并脑栓塞的患者抗栓治疗率不理想，HAS-BLED评分能很好地预测心房颤动合并 脑栓塞后的HT风险，另外，神经功能缺损较重、病灶范围大也是心房颤动合并脑栓塞患者发生HT的 危险因素。

Observation of the Status of Anticoagulation and Analysis of Hemorrhagic Transformation of Cerebral Embolism Patients with Atrial Fibrillation

Objective To observe the status of anticoagulation of patients with cerebral embolism and atrial
fibrillation through congestive heart failure, hypertension, age≥75 years old (doubled), diabetes
mellitus, stroke (doubled), vascular disease, aged between 65~74 years old and sex category (female)(CHA2DS2-VASc) score; to analyse the correlation of hypertension, abnormal renal and liver
function, stroke, bleeding, labile international normalized ratio (INR), age, drugs and alcohol intake
(HAS-BLED) score and other clinical risk factors with hemorrhagic transformation in patients with
cerebral embolism and atrial fibrillation.
Methods The clinical data were analyzed retrospectively in patients with cerebral embolism
andatrial fibrillation admitted in Department of Neurology in Beijing Boai Hospital from May 2012
to December 2014. The status of anticoagulation were observed in all patients who were divided
into three groups with CHA2DS2-VASc score: low risk group (score=0), moderate risk group
(score=1) and high risk group (score≥2). HAS-BLED score was used to analyse the difference
in hemorrhagic transformation (HT) rate between low-moderate group (score=0~2) and high risk
group (score≥3) and multivariate logistic regression analysis of several clinical variates was used
to find clinical risk factors related to HT.
Results A total of 101 patients were recruited. Before the onset of cerebral embolism of patients
with atrial fibrillation, according to CHA2DS2-VASc score, the rate of anticoagulationwas 66.7%
(2/3) and no patient received antiplatelet agent in low-risk group. The rate of anticoagulation
and antiplatelet agent was also 16.7% (2/12) in moderate-risk group. The rate of anticoagulation
was 19.8% (17/86) and antiplatelet agent was 14.0% (12/86) in high-risk group. The percentage
of patients who stopped anticoagulation treatment within 1 month before the onset of cerebral
embolism was 42.8% (9/21). The rate of anticoagulation was 68.3% (69/101) and antiplatelet agent
was 25.7% (26/101) in all patients with atrial fibrillation after the onset of cerebral embolism. After
cerebral embolism in patients with atrial fibrillation, according to HAS-BLED score, the rate of HT
was 37.5% (18/48) in low-risk group, while 58.5% (31/53) in high-risk group, there was statistic
signification in two groups (χ 2=4.443, P =0.035). The analysis of several clinical variates found that
there was statistic signification in NIHSS score (14.86±4.486 vs 11.94±5.648, P =0.006) and HASBLED
score (2.76±0.80 vs 2.21±0.96, P =0.003) between HT group and non HT group. The HT in
the group with bigger volume of the infarction was 57.9% (44/76) and HT in the group of smaller
volume of the infarction was 20% (5/25), which had significant difference (P =0.001). NIHSS score
(OR 1.106, 95%CI 1.106~1.216, P =0.036), HAS-BLED score (OR 2.353, 95%CI 1.326~4.175,
P =0.003) and the volumes of the infarction (OR 5.083, 95%CI 1.826~14.148, P =0.002) were risk
factors for HT in patients with cerebral embolism and atrial fibrillation.
Conclusion The rate of anticoagulant therapy is not satisfactory in patients with cerebral embolism
and atrial fibrillation. HT risk could be well forecasted with HAS-BLED score in patients with
cerebral embolism and atrial fibrillation. Severe neurofunction defect and bigger infarction volumes
are risk factors for HT in patients with cerebral embolism and atrial fibrillation.