Should patient characteristics influence target anticoagulation intensity for stroke prevention in nonvalvular atrial fibrillation?: the ATRIA study.
Should patient characteristics influence target anticoagulation intensity for stroke prevention in nonvalvular atrial fibrillation?: the ATRIA study.
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DOI：
10.1161/circoutcomes.108.830232
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发表时间：
2009-07
期刊：
影响因子：
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通讯作者：
Go AS
中科院分区：
文献类型：
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作者：
Singer DE;Chang Y;Fang MC;Borowsky LH;Pomernacki NK;Udaltsova N;Go AS
随机试验和观察性研究支持使用2.0至3.0的国际标准化比率(INR)目标来预防心房颤动(AF)中的缺血性中风。我们评估了INR目标是否应该根据选定的患者特征进行调整。我们进行了一项病例对照研究，嵌套在服用华法林的9,217名房颤患者中，以确定相对于INR 2.0-2.5，INR水平与血栓栓塞症(TE，主要是中风)和颅内出血(ICH)的几率之间的关系。我们在随访期间发现了396例TE和164例ICH病例。使用匹配的单变量分析和条件Logistic回归分析，将每个病例与四个在日历日期和中风风险因素上匹配的随机选择的对照进行比较。我们探讨了以下卒中危险因素对INR-结局关系的影响：既往卒中史、年龄和CHADS2危险评分。总体而言，TE的几率很低，并稳定在1.8印度卢比以上。与INR 2.0-2.5相比，在INR<；1.8，TE的相对优势显著增加(例如，OR=3.72；95%CI：2.67-5.19，INR 1.4-1.7)。当INR值为3.5时，发生脑出血的几率显著增加(例如，OR=3.56；95%CI：1.70-7.46，INR 3.6-4.5)。发生脑出血的相对几率始终较低，INR<；3.6。没有证据表明INR水平2.0会降低脑出血风险。这些风险模式并不因卒中病史、年龄或CHADS2风险评分而显著不同。我们的结果证实了目前房颤的INR 2.0-3.0标准在最佳的INR范围内。我们的发现不支持根据先前定义的卒中危险因素调整INR目标。
Randomized trials and observational studies support using an international normalized ratio (INR) target of 2.0 to 3.0 for preventing ischemic stroke in atrial fibrillation (AF). We assessed whether the INR target should be adjusted based on selected patient characteristics. We conducted a case-control study nested within the ATRIA cohort’s 9,217 AF patients taking warfarin to define the relationship between INR level and the odds of thromboembolism (TE, mainly stroke) and of intracranial hemorrhage (ICH) relative to INR 2.0-2.5. We identified 396 TE cases and 164 ICH cases during follow-up. Each case was compared with four randomly selected controls matched on calendar date and stroke risk factors using matched univariable analyses and conditional logistic regression. We explored modification of the INR-outcome relationships by the following stroke risk factors: prior stroke, age and CHADS2 risk score. Overall, the odds of TE were low and stable above INR 1.8. Compared to INR 2.0-2.5, the relative odds of TE increased strikingly at INR <1.8 (e.g., OR=3.72; 95% CI: 2.67-5.19, at INR 1.4-1.7). The odds of ICH increased markedly at INR values >3.5 (e.g., OR=3.56; 95% CI: 1.70-7.46, at INR 3.6-4.5). The relative odds of ICH were consistently low at INR <3.6. There was no evidence of lower ICH risk at INR levels<2.0. These patterns of risk did not differ substantially by history of stroke, age, or CHADS2 risk score. Our results confirm that the current standard of INR 2.0-3.0 for AF falls in the optimal INR range. Our findings do not support adjustment of INR targets according to previously defined stroke risk factors.