Epidemiology of Anticoagulation in Atrial Fibrillation

我们建议继续我们对北加州凯撒医疗保健计划(“凯泽”)超过13,559名房颤(房颤)患者的独特信息队列的研究。我们的总体目标仍然是通过改善抗凝剂治疗患者的选择和改善抗凝管理来优化房颤患者卒中的预防。房颤是最常见的严重心律失常。它的频率随着年龄的增长而显著增加，在80岁以上的人中达到近10%的患病率。房颤也是中风的一个强大的风险因素，使这种风险增加了5倍。随机试验(RCT)已经证实，抗凝在很大程度上消除了房颤造成的中风风险。尽管如此，华法林仍然是一种负担沉重且有风险的疗法。在现实世界的条件下，华法林疗法是否会被证明是有益的，还存在相当大的不确定性。指南呼吁长期抗凝，并在老年人中使用抗凝剂。然而，随机对照试验的时间相对较短，平均只有18个月的随访期，很少有年龄大于或等于80岁的患者被研究。在目前2.7年的资助期间，我们已经建立了方法来集合非常大的房颤队列，表征基线特征和华法林状态，并跟踪血栓栓子和出血事件。这是通过全面的自动化临床和管理Kaiser数据库，并辅之以病历审查有效地完成的。对我们的房颤队列的持续跟踪将对抗凝的长期影响和最年长的房颤患者的抗凝影响提供独特的评估。此外，我们将能够解决其他重要的争议，包括大于或等于65岁且没有其他卒中危险因素的患者是否需要抗凝，以及老年房颤患者的最佳抗凝强度。此外，我们还将讨论一项具有挑衅性的新发现，即雌激素替代疗法大大增加了患有房颤的女性中风的风险。总而言之，对我们队列的持续研究将有效地为许多患有房颤的美国老年人优化中风预防策略提供强有力的见解。

We propose to continue our studies of a uniquely informative cohort of greater than 13,559 patients with atrial fibrillation (AF) from Kaiser Medical Care Program of Northern California ("Kaiser"). Our overall goal remains to optimize prevention of stroke in AF by improving selection of patients treated with anticoagulants, and by improving the management of anticoagulation. AF is the most common significant cardiac rhythm disorder. Its frequency increases strikingly with age, reaching a prevalence of nearly 10 percent in those over age 80. AF is also a powerful risk factor for stroke, raising this risk 5-fold. Randomized trials (RCTs) have established that anticoagulation largely removes the stroke risk posed by AF. Nonetheless, warfarin remains a burdensome and risky therapy. There is considerable uncertainty whether warfarin therapy will prove beneficial under real-world conditions. Guidelines call for long-term anticoagulation, and for use of anticoagulants in the elderly. Yet, the RCTs were relatively brief, with a mean follow-up of only 18 months, and few patients greater than or equal to 80 years old were studied. During the 2.7 years of current funding we have established methods to assemble a very large AF cohort, characterize baseline features and warfarin status, and follow for thromboembolic and hemorrhagic events. This has been accomplished efficiently via comprehensive automated clinical and administrative Kaiser databases supplemented by medical chart review. Continued follow-up of our AF cohort will provide unique assessments of both the long-term impact of anticoagulation and the impact of anticoagulation among the oldest patients with AF. Further, we will be able to address other important controversies including the need for anticoagulation in patients greater than or equal to 65 years old without other risk factors for stroke, and the optimal intensity of anticoagulation in older AF patients. In addition, we will address the provocative new finding that estrogen replacement therapy substantially raises the risk of stroke among women with AF. In all, continued study of our cohort will efficiently provide powerful insights into optimizing stroke prevention strategies for the many older Americans with AF.