Warfarin in Complex Older Patients: Have we Reached a Tipping Point?
Warfarin in Complex Older Patients: Have we Reached a Tipping Point?
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华法林治疗复杂的老年患者：我们已经达到临界点了吗？
DOI：
10.1111/jgs.14747
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发表时间：
2017
影响因子：
6.3
通讯作者：
Gurwitz,JerryH
中科院分区：
文献类型：
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作者：
Gurwitz,JerryH
1921年，一位非常敏锐的兽医病理学家弗兰克·斯科菲尔德（Frank Schofield）将牛的出血性疾病与腐烂的甜三叶草联系起来。1939年，导致“出血性甜三叶草病”的药剂被确定为双酚。1948年，威斯康星校友研究基金会（Wisconsin Alumni Research Foundation）开发出了一种合成的cogener，并将其命名为华法林（warfarin），该基金会资助了这项研究并持有这项专利。华法林是作为一种老鼠药销售的，如果一位年轻的陆军新兵在1951年因摄入大量的灭鼠剂而自杀未遂，华法林的故事可能就会在那时结束。这一事件减轻了人们的恐惧，增加了人们对华法林用于治疗和预防血栓栓塞性疾病的兴趣。虽然华法林预防房颤卒中的疗效已在大型临床试验中明确确立，但即使在最理想的情况下，在现实世界的临床环境中实现安全有效的抗凝仍然是一个挑战。华法林治疗的最佳管理需要考虑一系列复杂的问题，包括药物和饮食的相互作用、临床状态的变化、患者的依从性、INR监测和结果的解释、剂量的修改、与患者或护理人员的沟通、未来试验的安排和表现。最重要的是，需要对其利弊进行持续评估，因为华法林是老年人用药相关伤害的主要原因之一。3,4,5,6最近发表的一项队列研究对30,000多名75岁或以上的房颤退伍军人进行了队列研究，这些退伍军人新转诊到VA抗凝诊所（接受华法林治疗），发现颅内出血（外伤性或非外伤性）的发生率为14.6 / 1000人年，缺血性卒中的发生率为13.4 / 1000人年。这些发现强调了“在考虑华法林治疗时，卫生保健专业人员和老年患者面临的非常困难的风险-收益权衡”。
In 1921, a very perceptive veterinary pathologist named Frank Schofield made the connection between a bleeding disorder in cattle and spoiled sweet clover. 1 The agent responsible for “hemorrhagic sweet clover disease” was identified as dicoumarol in 1939, and in 1948, a synthetic cogener was developed and named warfarin for the Wisconsin Alumni Research Foundation, which had funded the research and held the patent. Warfarin was marketed as a rat poison, and had a young Army recruit not survived a suicide attempt in 1951, following ingestion of large quantities of the rodenticide, the story of warfarin might have ended right then and there. That single incident allayed fears and increased interest in warfarin’s use in the treatment and prevention of thromboembolic disease.While the efficacy of warfarin for stroke prevention in atrial fibrillation has been unequivocally established in large clinical trials, achieving safe and effective anticoagulation in real-world clinical settings remains a challenge, even under the most ideal of circumstances. 2 Optimal management of warfarin therapy requires consideration of a complex array of issues including drug and dietary interactions, changing clinical status, patient adherence, INR monitoring and interpretation of results, dose modifications, communication with the patient or caregiver, and scheduling and performance of future tests. Most importantly, there needs to be ongoing assessment of benefits versus risks, as warfarin is among the leading causes of medication-related harm in older adults. 3, 4, 5, 6 A recently published cohort study of over 30,000 veterans with atrial fibrillation 75 years or older who were new referrals to VA anticoagulation clinics (for warfarin therapy) found that the incidence rate of intracranial bleeding (traumatic or nontraumatic) was 14.6 per 1000 person-years and the incidence rate of ischemic stroke was 13.4 per 1000 person-years. 7 These findings highlight “the very difficult risk-benefit trade-off that health care professionals and older patients face when considering warfarin therapy.”