Stroke in heart failure in sinus rhythm: the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial.
Stroke in heart failure in sinus rhythm: the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial.
复制标题
窦性心律心力衰竭中风：华法林与阿司匹林在降低心脏射血分数试验中的比较。
DOI：
10.1159/000352058
复制
发表时间：
2013
期刊：
影响因子：
--
通讯作者：
G
中科院分区：
文献类型：
--
作者：
Pullicino,PatrickM;Thompson,JohnLP;Sacco,RalphL;Sanford,AlexandraR;Qian,Min;Teerlink,JohnR;Haddad,Haissam;Diek,Monika;Freudenberger,RonaldS;Labovitz,ArthurJ;DiTullio,MarcoR;Lok,DirkJ;Ponikowski,Piotr;Anker,StefanD;G
背景华法林与阿司匹林降低心脏射血分数试验发现，华法林与阿司匹林在窦性心律低射血分数患者的主要结局方面无差异：首次发生缺血性卒中（IIS）84例，脑内出血7例或死亡531例。预先规定的次要分析显示，华法林在IIS中的风险比降低48%（p= 0.005）。脑栓塞可能是心力衰竭合并脑卒中的主要发病机制。我们研究了更详细的事后次要analysis.MethodsWe分型IIS到明确的，可能的和noncardioceactive使用中风预防房颤的方法为华法林的IIS的好处。统计学检验，按既往缺血性卒中或短暂性脑缺血发作分层，为独立泊松变量的条件二项分布率，为卒中亚型的Cochran-Mantel-Haenszel检验，为改良兰金评分（mRS）和国立卫生研究院卒中量表（NIHSS）分布的货车Elteren检验，以及比例的精确检验。163例阿司匹林患者有IIS。华法林的IIS发生率（0.727/100患者-年，PY）低于阿司匹林（1.36/100 PY，p= 0.003）。华法林组明确的心源性栓塞性IIS的发生率低于阿司匹林组（0.22 vs. 0.55/100 PY，p= 0.012）。华法林组可能的心源性栓塞性IIS的发生率低于阿司匹林组（0.37 vs. 0.67/100 PY，p= 0.063），但非心源性栓塞性IIS无差异：5（0.12/100 PY）vs. 6（0.15/100 PY，p= 0.768）。在发生IIS的患者中，各治疗组在致死性IIS、基线mRS、IIS后90天mRS以及IIS后mRS较基线的变化方面无差异。华法林组显示重度非致死性IIS比例较低的趋势[mRS 3-5; 3/23（13.0%）vs. 16/48（33.3%），p= 0.086]。有没有差异，NIHSS在中风的时间（p= 0.825）或后IIS的mRS（p= 0.948）之间的心源性栓塞，可能的心源性栓塞和非心源性栓塞中风，包括华法林和阿司匹林groups.ConclusionsThe观察到的好处减少IIS华法林相比，阿司匹林是最显着的心源性栓塞IIS的患者低射血分数在窦性心律。与阿司匹林相比，华法林治疗患者中重度IIS和可能的心源性栓塞性IIS的发生率更低的趋势支持了这一点。
BackgroundThe Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial found no difference between warfarin and aspirin in patients with low ejection fraction in sinus rhythm for the primary outcome: first to occur of 84 incident ischemic strokes (IIS), 7 intracerebral hemorrhages or 531 deaths. Prespecified secondary analysis showed a 48% hazard ratio reduction (p= 0.005) for warfarin in IIS. Cardioembolism is likely the main pathogenesis of stroke in heart failure. We examined the IIS benefit for warfarin in more detail in post hoc secondary analyses.MethodsWe subtyped IIS into definite, possible and noncardioembolic using the Stroke Prevention in Atrial Fibrillation method. Statistical tests, stratified by prior ischemic stroke or transient ischemic attack, were the conditional binomial for independent Poisson variables for rates, the Cochran-Mantel-Haenszel test for stroke subtype and the van Elteren test for modified Rankin Score (mRS) and National Institute of Health Stroke Scale (NIHSS) distributions, and an exact test for proportions.ResultsTwenty-nine of 1,142 warfarin and 55 of 1,163 aspirin patients had IIS. The warfarin IIS rate (0.727/100 patient-years, PY) was lower than for aspirin (1.36/100 PY, p= 0.003). Definite cardioembolic IIS was less frequent on warfarin than aspirin (0.22 vs. 0.55/100 PY, p= 0.012). Possible cardioembolic IIS tended to be less frequent on warfarin than aspirin (0.37 vs. 0.67/100 PY, p= 0.063) but noncardioembolic IIS showed no difference: 5 (0.12/100 PY) versus 6 (0.15/100 PY, p= 0.768). Among patients experiencing IIS, there were no differences by treatment arm in fatal IIS, baseline mRS, mRS 90 days after IIS, and change from baseline to post-IIS mRS. The warfarin arm showed a trend to a lower proportion of severe nonfatal IIS [mRS 3-5; 3/23 (13.0%) vs. 16/48 (33.3%), p= 0.086]. There was no difference in NIHSS at the time of stroke (p= 0.825) or in post-IIS mRS (p= 0.948) between cardioembolic, possible cardioembolic and noncardioembolic stroke including both warfarin and aspirin groups.ConclusionsThe observed benefits in the reduction of IIS for warfarin compared to aspirin are most significant for cardioembolic IIS among patients with low ejection fraction in sinus rhythm. This is supported by trends to lower frequencies of severe IIS and possible cardioembolic IIS in patients on warfarin compared to aspirin.