Initiation and persistence of warfarin or aspirin in patients with chronic atrial fibrillation in general practice: do the appropriate patients receive stroke prophylaxis?
Initiation and persistence of warfarin or aspirin in patients with chronic atrial fibrillation in general practice: do the appropriate patients receive stroke prophylaxis?
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DOI：
10.1111/j.1538-7836.2008.03059.x
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发表时间：
2008-09-01
影响因子：
10.4
通讯作者：
van Staa, T. P.
中科院分区：
文献类型：
--
作者：
Gallagher, A. M.;Rietbrock, S.;van Staa, T. P.
背景：实践指南建议慢性房颤（cAF）患者进行长期卒中预防。目的：检查治疗的开始和持续性以及影响cAF治疗选择的因素。患者/方法：本研究使用了全科医学研究数据库，包括英国全科医生的计算机化病历。纳入了2000年1月1日之后发生cAF的40岁以上患者。考克斯比例风险回归模型评价了华法林和阿司匹林的开始和治疗持续时间。停药定义为预期疗程结束后3个月内未重复处方。结果：研究人群包括41 910例cAF患者。与40-64岁的患者相比，老年患者（85岁以上）开始华法林治疗的可能性较小[相对发生率（RR）= 0.16，95%置信区间（CI）0.15-0.18]，开始阿司匹林治疗的可能性较大（RR = 1.66，95% CI 1.47-1.88）。痴呆（RR = 0.28，95% CI 0.17-0.44）和福尔斯（RR = 0.76，95% CI 0.70-0.83）病史也降低了开始华法林治疗的可能性。根据年龄和性别调整后，发现较高的卒中风险（CHADS（2）评分）与开始华法林或阿司匹林无关，这与当前指南的建议相反。华法林的一年持续性为70%，阿司匹林为50%。使用华法林和阿司匹林的老年患者的治疗持续性较高。较高的CHADS（2）评分仅与华法林的持续性改善相关。结论：在一般实践中，cAF患者长期接受治疗的可能性较低，表明在临床试验中观察到的所有获益在常规临床实践中可能无法实现。
Background: Practice guidelines recommend long-term stroke prophylaxis in patients with chronic atrial fibrillation (cAF). Objectives: To examine treatment initiation and persistence and factors that influence the choice of cAF treatment. Patients/methods: This study used the General Practice Research Database, including computerized medical records of general practitioners in the UK. Patients aged 40+ years with cAF after 1 January 2000 were included. Cox proportional hazards regression models evaluated initiation and treatment continuation over time of warfarin and aspirin. Treatment discontinuation was defined as no repeat prescription within a three-month period after the expected end of the treatment course. Results: The study population included 41 910 cAF patients. Elderly patients (aged 85+) were less likely to start warfarin [relative rate (RR) = 0.16, 95% confidence interval (CI) 0.15-0.18] and more likely to start aspirin (RR = 1.66, 95% CI 1.47-1.88) than patients aged 40-64 years. A history of dementia (RR = 0.28, 95% CI 0.17-0.44) and falls (RR = 0.76, 95% CI 0.70-0.83) also reduced the likelihood of warfarin initiation. Adjusting for age and gender, higher stroke risk (CHADS(2) score) was not found to be associated with initiation of warfarin or aspirin contrary to current guidelines recommendations. One-year persistence was 70% for warfarin and 50% for aspirin. Treatment persistence was higher in elderly patients using warfarin and aspirin. A higher CHADS(2) score was associated with improved persistence only with warfarin. Conclusions: The low likelihood of patients with cAF in general practice remaining on treatment long-term indicates that not all benefits as observed in clinical trials may be achieved in usual clinical practice.