Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation.
Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation.
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DOI：
10.1161/jaha.115.003074
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发表时间：
2016-02-23
影响因子：
5.4
通讯作者：
Noseworthy PA
中科院分区：
文献类型：
--
作者：
Yao X;Abraham NS;Alexander GC;Crown W;Montori VM;Sangaralingham LR;Gersh BJ;Shah ND;Noseworthy PA
与华法林相比，非维生素K拮抗剂口服抗凝剂（NOACs）具有给药方便、药物相互作用少、不需要持续监测等优点。我们试图评估这些优势是否转化为改善依从性，以及依从性是否与房颤患者预后的改善有关。我们使用美国大型商业保险数据库进行了回顾性队列分析，确定了2010年11月1日至2014年12月31日期间接受华法林、达比加群、利伐沙班或阿哌沙班治疗的64661例心房颤动患者。在中位1.1 y的随访期间，47.5%的NOAC患者的住院天数比例≥80%，而华法林患者的这一比例为40.2% （P<0.001）。CHA 2 DS 2‐VASc（基于充血性心力衰竭、高血压、年龄65-74岁、年龄≥75岁、糖尿病、既往卒中或短暂性脑缺血发作、血管疾病、性别类别的风险）评分≥4的患者在不服用抗凝治疗≥1个月与<1周时卒中风险增加（1 - 3个月：风险比[HR] 1.96, 3-6个月：HR 2.64，≥6个月：HR 3.66，均P<0.001）。CHA 2 DS 2‐VASc评分为2或3的患者在不服用抗凝治疗≥6个月时卒中风险增加（HR 2.73， P<0.001）。在这些CHA 2 DS 2‐VASc评分≥2的患者中，不依从性与颅内出血无关。在CHA 2 DS 2‐VASc评分为0或1的患者中，不服用抗凝治疗的时间与卒中无关，但不服用抗凝治疗≥3个月与出血显著减少相关。在实践中抗凝治疗的依从性很差，并且可以通过NOACs适度改善。在CHA 2 DS 2‐VASc评分≥2的患者中，坚持治疗似乎是最重要的，而在CHA 2 DS 2‐VASc评分为0或1的患者中，抗凝治疗的益处可能不会超过其危害。
In comparison to warfarin, non–vitamin K antagonist oral anticoagulants (NOACs) have the advantages of ease of dosing, fewer drug interactions, and lack of need for ongoing monitoring. We sought to evaluate whether these advantages translate to improved adherence and whether adherence is associated with improved outcomes in patients with atrial fibrillation. We performed a retrospective cohort analysis by using a large US commercial insurance database to identify 64 661 patients with atrial fibrillation who initiated warfarin, dabigatran, rivaroxaban, or apixaban treatment between November 1, 2010, and December 31, 2014. During a median of 1.1 y of follow‐up, 47.5% of NOAC patients had a proportion of days covered of ≥80%, compared with 40.2% in warfarin patients (P<0.001). Patients with CHA 2 DS 2‐VASc (risk based on the presence of congestive heart failure, hypertension age 65–74 y, age ≥75 y, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, sex category) score ≥4 were at increased risk of stroke when they were not taking anticoagulation ≥1 month versus <1 week (1–3 months: hazard ratio [HR] 1.96, 3–6 months: HR 2.64, ≥6 months: HR 3.66; all P<0.001). Patients with CHA 2 DS 2‐VASc score 2 or 3 were at increased risk of stroke when they were not taking anticoagulation ≥6 months (HR 2.73, P<0.001). In these patients with CHA 2 DS 2‐VASc score ≥2, nonadherence was not associated with intracranial hemorrhage. Among patients with CHA 2 DS 2‐VASc score 0 or 1, time not taking anticoagulation was not associated with stroke, but not taking anticoagulation ≥3 months was associated with a significant reduction of bleeding. Adherence to anticoagulation is poor in practice and may be modestly improved with NOACs. Adherence to therapy appears to be most important in patients with CHA 2 DS 2‐VASc score ≥2, whereas the benefits of anticoagulation may not outweigh the harms in patients with CHA 2 DS 2‐VASc score 0 or 1.