Net clinical benefit of warfarin in individuals with atrial fibrillation across stroke risk and across primary and secondary care.
Net clinical benefit of warfarin in individuals with atrial fibrillation across stroke risk and across primary and secondary care.
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DOI：
10.1136/heartjnl-2016-309910
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发表时间：
2017-02
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影响因子：
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通讯作者：
Hemingway H
中科院分区：
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作者：
Allan V;Banerjee A;Shah AD;Patel R;Denaxas S;Casas JP;Hemingway H
研究华法林在房颤（AF）患者中的净临床获益（NCB），包括卒中风险和初级和二级护理。我们在英格兰（1998-2010年）对70206名在初级（n= 29568）或二级护理（n= 40638）中有房颤诊断初始记录的个体进行了一项关联电子健康记录队列研究。 我们根据CHA 2DS 2-VASc评分定义卒中风险，并对7005例缺血性卒中（IS）和906例出血性卒中（HS）的个体进行了中位2.2年的随访。 我们计算了使用和不使用华法林时IS和HS的发生率（IR）和每100人-年（PY）的95% CI（IR（95% CI）/100 PY），以及使用华法林每100 PY的NCB（即避免的IS数量）（NCB（95% CI）/100 PY）。 与在二级保健中有初始诊断记录的个体相比，在初级保健中的个体IS风险评分较低（CHA 2DS 2-VASc≤2：30.8% vs 20.6%），IS的总体发生率较低（IR（95% CI）/100 PY：2.3（2.2至2.4）vs 4.3（4.2至4.4），p值=0.00）;然而在CHA 2DS 2-VASc=0的个体中，1或2，在初级保健或二级保健中有初始诊断记录的患者之间IS发生率无差异（IR（95% CI）/100 PY：0.2（0.1至0.3）vs 0.3（0.2至0.5），p值=0.16），（IR（95% CI）/100 PY：0.6（0.4至0.7）vs 0.7（0.6至0.9），p值=0.08）和（IR（95% CI）/100 PY：1.1（1.00至1.3）vs 1.4（1.2至1.6），p值=0.05）。对于CHA 2DS 2-VASc=0、1和2，与未使用华法林相比，IS的IR分别为（IR（95% CI）/100 PY：0.4（0.2至0.8）vs 0.2（0.1至0.3），p值=0.16）、（IR（95% CI）/100 PY：0.4（0.3至0.7）vs 0.7（0.6至0.8），p值=0.03）和（IR（95% CI）/100 PY：0.8（0.7至1.0）vs 1.4（1.3至1.6），p值=0.00）。 我们发现华法林的显著阳性NCB为男性CHA 2DS 2-VASc≥2（NCB（95% CI）/100 PY：0.5（0.1 - 0.9））和女性CHA 2DS 2-VASc≥3（NCB（95% CI）/100 PY：1.5（1.1 - 1.9））。 CHA 2DS 2-VASc准确地对AF患者在初级和二级护理中的IS风险进行了分层。然而，在CHA 2DS 2-VASc=1时，缺血性卒中的发生率低于先前报告的发生率，这可能会改变在这些个体中开始华法林抗凝治疗的决定。
To investigate net clinical benefit (NCB) of warfarin in individuals with atrial fibrillation (AF) across stroke risk and across primary and secondary care. We conducted a linked electronic health record cohort study of 70 206 individuals with initial record of diagnosis of AF in primary (n=29 568) or secondary care (n=40 638) in England (1998–2010). We defined stroke risk according to the CHA2DS2-VASc score, and followed individuals over a median 2.2 years for 7005 ischaemic strokes (IS) and for 906 haemorrhagic strokes (HS). We calculated incidence rates (IRs) and 95% CIs per 100 person-years (PYs) (IR (95% CI)/100 PY) of IS and HS, with and without use of warfarin, and the NCB (ie, number of IS avoided) per 100 PYs of warfarin use (NCB (95% CI)/100 PY). Compared with individuals with initial record of diagnosis in secondary care, those in primary care had lower scores of IS risk (CHA2DS2-VASc≤2: 30.8% vs 20.6%), and lower overall incidence of IS (IR (95% CI)/100 PY: 2.3 (2.2 to 2.4) vs 4.3 (4.2 to 4.4), p value=0.00); however among individuals with CHA2DS2-VASc=0, 1 or 2 there were no differences in IS rate between those with initial record of diagnosis in primary care or secondary care (IR (95% CI)/100 PY: 0.2 (0.1 to 0.3) vs 0.3 (0.2 to 0.5), p value=0.16), (IR (95% CI)/100 PY: 0.6 (0.4 to 0.7) vs 0.7 (0.6 to 0.9), p value=0.08) and (IR (95% CI)/100 PY: 1.1 (1.00 to 1.3) vs 1.4 (1.2 to 1.6), p value=0.05), respectively. For CHA2DS2-VASc=0, 1 and 2, IRs of IS with versus without warfarin were (IR (95% CI)/100 PY: 0.4 (0.2 to 0.8) vs 0.2 (0.1 to 0.3), p value=0.16), (IR (95% CI)/100 PY: 0.4 (0.3 to 0.7) vs 0.7 (0.6 to 0.8), p value=0.03) and (IR (95% CI)/100 PY: 0.8 (0.7 to 1.0) vs 1.4 (1.3 to 1.6), p value=0.00), respectively. We found a significant positive NCB of warfarin from CHA2DS2-VASc≥2 in men (NCB (95% CI)/100 PY: 0.5 (0.1 to 0.9)) and from CHA2DS2-VASc≥3 in women (NCB (95% CI)/100 PY: 1.5 (1.1 to 1.9)). CHA2DS2-VASc accurately stratifies IS risk in individuals with AF across both primary and secondary care. However, the incidence rate of ischaemic stroke at CHA2DS2-VASc=1 are lower than previously reported, which may change the decision to start anticoagulation with warfarin in these individuals.