Association Between CHADS2 Risk Factors and Anticoagulation-Related Bleeding: A Systematic Literature Review
Association Between CHADS2 Risk Factors and Anticoagulation-Related Bleeding: A Systematic Literature Review
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DOI：
10.4065/mcp.2010.0755
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发表时间：
2011-06-01
影响因子：
8.9
通讯作者：
Coleman, Craig I.
中科院分区：
文献类型：
--
作者：
Chen, Wendy T.;White, C. Michael;Coleman, Craig I.
目的：确定当患者存在CHADS（2）风险因素时，支持出血风险加重的证据强度（慢性心力衰竭、高血压、高龄、糖尿病和既往卒中/短暂性脑缺血发作）接受华法林治疗。MEDLINE的系统性文献检索（1950年1月1日至2009年12月22日）和科克伦中心（截至12月22日，2009），以确定报告CHADS（2）协变量与接受华法林患者出血风险之间相关性的多变量结果的研究。评价每个协变量与特定类型出血的相关性。使用与医疗保健研究和质量机构推荐的方法一致的方法，将个体评价评定为良好、一般或较差。每个CHADS（2）协变量和特定类型出血之间的关联强度使用推荐评估、发展和评价标准分级来确定，对于整个证据体系，其为不足、非常低、低、中等或高。结果：识别了41项研究，报告了127项CHADS（2）协变量和出血风险之间关联的多变量评价。没有CHADS（2）协变量具有与任何出血类型相关的高强度证据。对于绝大多数评价，协变量与出血之间的证据强度较低。高龄是唯一具有中等强度相关证据的协变量;这是大出血最强的独立阳性预测因子。无论是所有纳入的研究，还是仅评估房颤患者的研究，都观察到了类似的结果。结论：CHADS（2）协变量与出血风险增加之间的相关性很弱，除了年龄。鉴于已知CHADS（2）评分与卒中风险之间的相关性，决定是否使用华法林应更多地考虑患者的卒中风险，而不是出血风险。
OBJECTIVE: To determine the strength of evidence supporting an accentuated bleeding risk when patients with CHADS(2) risk factors (chronic heart failure, hypertension, advanced age, diabetes, and prior stroke/transient ischemic attack) receive warfarin.METHODS: A systematic literature search of MEDLINE (January 1, 1950, through December 22, 2009) and Cochrane CENTRAL (through December 22, 2009) was conducted to identify studies that reported multivariate results on the association between CHADS(2) covariates and risk of bleeding in patients receiving warfarin. Each covariate was evaluated for its association with a specific type of bleeding. Individual evaluations were rated as good, fair, or poor using methods consistent with those recommended by the Agency for Healthcare Research and Quality. The strength of the associations between each CHADS(2) covariate and a specific type of bleeding was determined using Grading of Recommendations Assessment, Development and Evaluation criteria as insufficient, very low, low, moderate, or high for the entire body of evidence.RESULTS: Forty-one studies were identified, reporting 127 multivariate evaluations of the association between a CHADS(2) covariate and bleeding risk. No CHADS(2) covariate had a high strength of evidence for association with any bleeding type. For the vast majority of evaluations, the strength of evidence between covariates and bleeding was low. Advanced age was the only covariate that had a moderate strength of evidence for association; this was the strongest independent positive predictor for major bleeding. Similar findings were observed regardless of whether all included studies, or only those evaluating patients with atrial fibrillation, were assessed.CONCLUSION: The associations between CHADS(2) covariates and increased bleeding risk were weak, with the exception of age. Given the known association of the CHADS(2) score and stroke risk, the decision to prescribe warfarin should be driven more by patients' risk of stroke than by the risk of bleeding.