Modifiers of Symptomatic Embolic Risk in Infective Endocarditis
Modifiers of Symptomatic Embolic Risk in Infective Endocarditis
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DOI：
10.4065/mcp.2011.0111
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发表时间：
2011-11-01
影响因子：
8.9
通讯作者：
Baddour, Larry M.
中科院分区：
文献类型：
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作者：
Anavekar, Nandan S.;Schultz, Jason C.;Baddour, Larry M.
目的：为了确定以前的抗血小板和他汀类药物治疗对有症状的栓塞事件的影响在本地瓣膜感染性心内膜炎（IE）患者和方法：我们研究了一个回顾性队列的成年患者诊断IE谁提出的马约诊所（罗切斯特，明尼苏达州）从2003年1月1日至2006年12月31日。将患者分为感染前接受治疗的患者和未接受抗血小板治疗和单独他汀类药物治疗的对照组。由于回顾性研究设计以及非随机化治疗组，使用倾向评分法解释可能影响治疗分配的混杂因素。抗血小板治疗包括阿司匹林、双嘧达莫、氯吡格雷、噻氯普定或这些药物的任何组合。他汀类药物治疗包括阿托伐他汀、辛伐他汀、普伐他汀、洛伐他汀、瑞舒伐他汀或氟伐他汀。主要终点是住院前或住院期间发生的症状性栓塞事件。采用多变量logistic回归分析评估抗血小板和他汀类药物持续每日治疗对症状性栓塞风险的倾向性调整效应。同样，考克斯比例风险回归用于测试与6个月的死亡率为每一个treatment.RESULTS：研究队列包括283例自体瓣膜IE患者的独立关联。28名既往接受连续抗血小板治疗的患者（24.1%）发生了症状性栓塞事件，而66名未接受此类治疗的患者（39.5%）发生了症状性栓塞事件。调整倾向治疗后，抗血小板治疗对栓塞风险的影响无统计学意义（比值比，0.71; 95%置信区间[CI]，0.37-1.36; P= 0.30）。只有14例（18.2%）接受过既往连续他汀类药物治疗的患者发生了症状性栓塞事件，而203例未接受过治疗的患者中有80例（39.4%）发生了症状性栓塞事件。调整他汀类药物治疗倾向后，他汀类药物的获益显著（比值比，0.30; 95%CI，0.14-0.62; P= 0.001）。整个队列的6个月死亡率为28%（95% CI，23%-34%）。在既往接受过和未接受过抗血小板治疗的患者（P=.91）或既往接受过和未接受过他汀类药物治疗的患者（P=.87）之间，6个月死亡率的倾向调整率无显著差异。结论：在IE发作前接受持续每日他汀类药物治疗的患者中，与IE相关的症状性栓塞发生率降低。尽管在接受抗血小板药物治疗的患者中观察到的栓塞事件较少，但在调整倾向因素后未发现显著相关性。这些药物及其对IE患者后续栓塞的潜在影响的持续评价是必要的。
OBJECTIVE: To ascertain the impact of prior antiplatelet and statin therapy on symptomatic embolic events In native valve infective endocarditis (IE).PATIENTS AND METHODS: We studied a retrospective cohort of adult patients with a diagnosis of IE who presented to Mayo Clinic (Rochester, MN) from January 1, 2003, to December 31, 2006. Patients were grouped into those who received treatment before infection or controls who did not receive treatment for both antiplatelet therapy and, separately, statin therapy. Because of the retrospective study design and thus the nonrandomized treatment groups, a propensity score approach was used to account for the confounding factors that may have influenced treatment allocation. Antiplatelet therapy included aspirin, dipyridamole, clopidogrel, ticlopldine or any combination of these agents. Statin therapy included atorvastatin, simvastatin, pravastatin, lovastatin, rosuvastatin, or fluvastatin. The primary end point was a symptomatic embolic event that occurred before or during hospitalization. Multivariable logistic regression was used to assess the propensity-adjusted effects of continuous daily therapy with antiplatelet and statin agents on risk of symptomatic emboli. Likewise, Cox proportional hazards regression was used to test for an independent association with 6-month mortality for each of the treatments.RESULTS: The study cohort comprised 283 patients with native valve IE. Twenty-eight patients (24.1%) who received prior continuous antiplatelet therapy developed a symptomatic embolic event compared with 66 (39.5%) who did not receive such treatment. After adjusting for propensity to treat, the effect of antiplatelet therapy on embolic risk was not statistically significant (odds ratio, 0.71; 95% confidence interval [CI], 0.37-1.36; P=.30). Only 14 patients (18.2%) who received prior continuous statin therapy developed a symptomatic embolic event compared with 80 (39.4%) of the 203 patients who did not. After adjusting for propensity to treat with statin therapy, the benefit attributable to statins was significant (odds ratio, 0.30; 95% CI, 0.14-0.62; P=.001). The 6-month mortality rate of the entire cohort was 28% (95% CI, 23%-34%). No significant difference was found In the propensity-adjusted rate of 6-month mortality between patients who had and had not undergone prior antiplatelet therapy (P=.91) or those who had and had not undergone prior statin therapy (P=.87).CONCLUSION: The rate of symptomatic emboli associated with IE was reduced In patients who received continuous daily statin therapy before onset of IE. Despite fewer embolic events observed in patients who received antiplatelet agents, a significant association was not found after adjusting for propensity factors. A continued evaluation of these drugs and their potential impact on subsequent embolism among IE patients is warranted.