本文選題：心房顫動 + 口服抗凝劑��； 參考：《山東大學》2017年碩士論文

【摘要】：[目的]在一組單中心"真實世界"的心房顫動(房顫)病人中前瞻性分析房顫人群的流行病學特點以及抗凝治療現(xiàn)狀。[方法]自2016.3至2016.9前瞻性納入在山東大學齊魯醫(yī)院青島院區(qū)就診的房顫病人509例,觀察性分析病人的流行病學特點、抗栓/抗凝治療率、栓塞風險評估、隨訪6個月時的栓塞事件及出血事件的發(fā)生率,分析影響抗凝治療率的主要因素,并探索提高高栓塞風險的房顫病人抗凝治療率的措施。[結(jié)果]共462例房顫病人(平均年齡71.2± 12.7歲)完成了該觀察性研究,其中男性274例(59.3%)、女性例188(40.7%)。常見的伴隨疾病有高血壓(78.4%)、糖尿病(24.9%)、冠心病(20.8%)和心力衰竭(13.4%)。共有126例(27.3t%)未行抗栓治療,174例(37.7,%)抗血小板藥物治療,162例(35.0%)行抗凝藥物治療,其中101例(62.3%)服用華法林,51例(37.7,%)服用新型口服抗凝劑(N0AC)達比加群酯。在30例瓣膜性房顫病人中24例行華法林抗凝治療,治療率為80%,另外4例抗血小板治療,2例未行抗栓治療。在432例非瓣膜性房顫病人中,CHADS2評分為2.1±1.4,CHA2DS2-VASc評分為4.2±1.9。全部病人的HAS-BLED)評分為2.5±1.4。在126例未行抗栓治療的房顫病人中,主要原因包括:服用華法林檢測INR值繁瑣(37%)、擔心出血風險(29%)、NOACs費用高(21%)、不了解抗凝治療目的(13%)等。在HAS-BLED)評分≥5分的病人中,抗凝治療率為0%,而抗血小板治療率為100%。經(jīng)過6個月的隨訪,共有38例發(fā)生了血栓栓塞事件,均為非瓣膜性房顫病人,總體栓塞事件發(fā)生率為8.2%,其中未治療組15例(11.9%),抗血小板治療組16例(9.2%),抗凝治療組7例(4.3%)(P0.05)。影響栓塞事件結(jié)局的危險因素包括:左心房直徑、既往栓塞病史、年齡和外周動脈疾病。多因素分析顯示,既往栓塞史可顯著增加栓塞風險。與未抗栓治療組相比,抗血小板治療組的血栓栓塞事件相對危險下降22.7%,但未達統(tǒng)計學差異(P=0.283,OR=0.749,95%CI0.356-1.579),而抗凝治療組的血栓栓塞事件發(fā)生率顯著降低,相對危險度下降63.9%(P=0.015,0R=0.334,95%CI 0.132-0.847)�？寡“逯委熃M和抗凝治療組的栓塞事件發(fā)生率雖然未達到統(tǒng)計學差異,但抗凝治療組比抗血小板治療組的相對危險度減少53.3%(P=0.059,0R=0.446,95%CI 為 0.179-1.114)。栓塞事件發(fā)生率隨 CHADS2、CHA2DS2-VASc評分的增加而增加,栓塞組與未栓塞組的CHADS2評分分別為3.05±1.49 比 2.06±1.38(P0.001),CHA2DS2-VASc 評分分別為 5.53±1.72 比4.11±1.82(/0.001)。在未抗栓治療組,CHADS2=0的病人其栓塞事件發(fā)生率高達13.0%,而在CHA2DS2-VASc=0或1的病人,其栓塞事件發(fā)生率為0。采用Roc曲線計算C-statistic值的結(jié)果表明,CHA2DS2-VASc評分(0.717,CI 0.635-0.798,P0.001)比 CHADS2 評分(0.698,CI0.608-0.707,P0.001)具有更高的栓塞風險預測價值。共發(fā)生5例大出血事件,其中瓣膜性房顫病人1例,非瓣膜性房顫病人4例;抗凝治療組3例,抗血小板治療組1例。[結(jié)論]房顫好發(fā)于老年人,男性多于女性,抗凝治療率總體偏低,且隨著CHA2DS2-VASc評分的增加逐漸降低,而抗血小板治療率逐漸增加。未行抗凝治療主要原因包括服用華法林檢測INR值繁瑣、擔心出血風險、NOACs費用昂貴、不了解抗凝治療目的等�？寡“逯委熚达@著降低栓塞事件發(fā)生率,而抗凝治療可顯著降低栓塞事件的發(fā)生率。CHA2DS2-VASc評分系統(tǒng)具有比CHADS2評分系統(tǒng)更高的栓塞風險預測敏感性。提高醫(yī)生對房顫管理指南的依從性、將NOACs藥物納入醫(yī)保目錄、加強對房顫病人的健康宣教和是提高高栓塞風險的房顫病人抗凝治療率、降低栓塞事件發(fā)生率的重要措施。
[Abstract]:[Objective] to prospectively analyze the epidemiological characteristics of atrial fibrillation and the status of anticoagulant therapy in a group of patients with single center "real world" atrial fibrillation (atrial fibrillation). [Methods] 509 cases of atrial fibrillation in Qingdao Hospital of Qilu Hospital of Shandong University were prospectively included in 509 cases. The epidemiological characteristics of the patients were analyzed by observational analysis. Embolic / anticoagulant therapy rate, embolization risk assessment, the incidence of embolism events and bleeding events at 6 months of follow-up, analysis of the main factors affecting the rate of anticoagulant therapy, and the exploration of measures to improve the anticoagulant rate of atrial fibrillation patients with high risk of embolism. [results] 462 patients with atrial fibrillation (average age 71.2 + 12.7 years old) completed the observational study, In 274 cases (59.3%) and 188 (40.7%) for women, common associated diseases were hypertension (78.4%), diabetes (24.9%), coronary heart disease (20.8%) and heart failure (13.4%). There were 126 cases (27.3t%) without antithrombotic therapy, 174 (37.7,%) antithrombotic therapy, 162 (35%) treated with anticoagulant, among them, warfarin was taken. In 30 patients with valvular atrial fibrillation, 24 of 30 patients with valvular atrial fibrillation were treated with warfarin anticoagulant therapy, the treatment rate was 80%, 4 were antiplatelet therapy and 2 had no antithrombotic therapy. In 432 patients with non valvular atrial fibrillation, the CHADS2 score was 2.1 + 1.4 and the CHA2DS2-VASc score was 4.2 + 1.9. in all patients with HAS-BLED. The main reasons were 2.5 + 1.4. in 126 cases of atrial fibrillation patients without antithrombotic treatment. The main reasons were: the Hua Falin test was tedious (37%), the risk of bleeding (29%), the high cost of NOACs (21%), the anticoagulant treatment (13%). The anticoagulant rate was 0% in the patients with the score of 5 in HAS-BLED, and the antiplatelet therapy rate was 100%. 6. A total of 38 patients were followed up with thromboembolic events, all of which were non valvular atrial fibrillation, with a total incidence of 8.2%, including 15 in the untreated group (11.9%), 16 in the antiplatelet therapy group (9.2%) and 7 in the anticoagulant group (4.3%) (P0.05). The risk factors affecting the outcome of the embolus event included the left atrial diameter, the history of previous embolism. Age and peripheral arterial disease. Multivariate analysis showed that previous embolic Shi Ke significantly increased the risk of embolism. Compared with the non antithrombotic treatment group, the relative risk of thromboembolism in the antithrombotic therapy group decreased by 22.7%, but was not statistically significant (P=0.283, OR=0.749,95%CI0.356-1.579), while the incidence of thromboembolism events in the anticoagulant treatment group was significant. The relative risk decreased by 63.9% (P=0.015,0R=0.334,95%CI 0.132-0.847). The incidence of thromboembolism events in the antiplatelet therapy group and the anticoagulant treatment group was not statistically significant, but the relative risk of the anticoagulant therapy group decreased by 53.3% (P= 0.059,0R=0.446,95%CI 0.179-1.114). The rate increased with the increase of CHADS2 and CHA2DS2-VASc scores. The CHADS2 score of the embolization group and the non embolic group was 3.05 + 1.49 to 2.06 + 1.38 (P0.001), and the CHA2DS2-VASc score was 5.53 + 1.72 to 4.11 + 1.82 (/0.001). In the non antithrombotic treatment group, the incidence of Embolism Events was up to 13% in the patients with CHADS2=0 and in CHA2DS2-VASc=0 or 1. Patients, the incidence of their embolic events was 0. using the Roc curve to calculate the C-statistic value. The CHA2DS2-VASc score (0.717, CI 0.635-0.798, P0.001) had a higher predictive value than the CHADS2 score (0.698, CI0.608-0.707, P0.001). There were 5 cases of massive hemorrhage, including 1 patients with valvular atrial fibrillation and non valvular atrial fibrillation. There were 4 cases of patients, 3 cases in anticoagulant treatment group and 1 cases in antiplatelet therapy group. [Conclusion] atrial fibrillation is better in the elderly, more men than women, and the rate of anticoagulant treatment is generally low, and with the increase of CHA2DS2-VASc score, the rate of antiplatelet therapy is gradually increased. The main reason for non anticoagulant treatment includes the fussy INR value of warfarin test. The risk of bleeding, NOACs is expensive and does not understand the purpose of anticoagulant therapy. Antiplatelet therapy does not significantly reduce the incidence of embolic events, and anticoagulant therapy can significantly reduce the incidence of embolic events in the.CHA2DS2-VASc scoring system with higher risk pretest sensitivity than the CHADS2 scoring system. In terms of sex, NOACs drugs are included in the medical insurance catalogue, strengthening health education for patients with atrial fibrillation and improving the rate of anticoagulant therapy for patients with high risk of embolism and reducing the incidence of embolic events.
【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R541.75

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