Relation of Race, Apparent Disability, and Stroke Risk With Warfarin Prescribing for Atrial Fibrillation in Patients Receiving Maintenance Hemodialysis.
Relation of Race, Apparent Disability, and Stroke Risk With Warfarin Prescribing for Atrial Fibrillation in Patients Receiving Maintenance Hemodialysis.
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种族、明显残疾和中风风险与接受维持性血液透析患者治疗心房颤动的华法林处方的关系。
DOI：
10.1016/j.amjcard.2018.11.020
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发表时间：
2019
期刊：
影响因子：
--
通讯作者：
Liu,Jiannong
中科院分区：
文献类型：
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作者：
Wetmore,JamesB;Peng,Yi;Gilbertson,DavidT;Liu,Jiannong
关于华法林是如何用于慢性房颤（AF）维持透析患者预防卒中的知之甚少。我们研究了房颤诊断后华法林的使用模式和相关因素。这项回顾性队列分析研究了2008年1月1日至2010年6月30日接受维持透析的美国医疗保险患者。人口统计学、合并症和基于医疗设备索赔的持久残疾代理评分可预测房颤诊断后的华法林处方。该分析包括8,964例非瓣膜性房颤患者。与未使用者相比，华法林使用者更年轻（年龄65.4 ± 12.1岁vs 67.0 ± 12.9岁），更可能是男性（54.3% vs 52.8%）和白色人种（64.0% vs 59.6%）。在调整其他因素后，非白色与白色相比，种族与30天内华法林使用量显著减少相关：黑人患者的比值比（OR），95%置信区间（CI）为0.80，0.71 - 91;亚洲人为0.57，0.43 - 0.76;其他种族为0.74，0.49 - 1.12。随着高血压、肾功能和肝功能异常、卒中-出血不稳定INR、老年药物或酒精（HAS-BLED）出血风险评分增加，接受华法林治疗的患者的死亡率降低（OR 0.82，95% CI 0.73 - 0.92，HAS-BLED评分3 - 4 vs 2; 0.38，0.26 - 0.57，评分≥ 5 vs 2）。然而，随着CHA 2DS 2-Vasc卒中风险评分的增加，华法林的使用倾向于减少（OR 0.90，95% CI 0.78至1.03，p = 0.13，CHA 2DS 2-Vasc评分4 vs 1至3; 0.69，0.61至0.78，p < 0.0001，评分5 vs 1至3）。总之，在为维持性透析患者开华法林时，供应商似乎更重视出血风险而不是卒中预防潜力。即使考虑到其他因素，少数种族接受华法林的频率也远低于白人。
Little is known about how warfarin is prescribed for stroke prevention in maintenance dialysis patients with chronic atrial fibrillation (AF). We examined patterns of warfarin use, and associated factors, after AF diagnosis. This retrospective cohort analysis studied US Medicare patients receiving maintenance dialysis January 1, 2008, to June 30, 2010. Demographics, co-morbidity, and a durable medical equipment claims-based disability proxy score predicted warfarin prescription after AF diagnosis. The analysis included 8,964 patients with nonvalvular AF. Compared with nonusers, warfarin users were younger (age 65.4 ± 12.1 vs 67.0 ± 12.9 years) and more likely to be men (54.3% vs 52.8%) and of white race (64.0% vs 59.6%). After adjustment for other factors, nonwhite, versus white, race was associated with significantly less warfarin use within 30 days: odds ratios (ORs), 95% confidence intervals (CIs), were 0.80, 0.71 to 91, for black patients; 0.57, 0.43 to 0.76, for Asians; and 0.74, 0.49 to 1.12, for members of other races. Percentages of patients receiving warfarin decreased as Hypertension Abnormal renal and liver function Stroke-Bleeding Labile INR Elderly Drugs or alcohol (HAS-BLED) bleeding risk score increased (OR 0.82, 95% CI 0.73 to 0.92, HAS-BLED score 3 to 4 versus 2; 0.38, 0.26 to 0.57, score ≥ 5 vs 2). However, as CHA2DS2-Vasc stroke-risk score increased, warfarin use tended to decrease (OR 0.90, 95% CI 0.78 to 1.03, p = 0.13, CHA2DS2-Vasc score 4 versus 1 to 3; 0.69, 0.61 to 0.78, p < 0.0001, score 5 vs 1 to 3). In conclusion, providers appear to weigh bleeding risk more heavily than stroke-prevention potential when prescribing warfarin for maintenance dialysis patients. Racial minorities received warfarin substantially less often than whites, even after accounting for other factors.