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背景目前国际指南提倡采用卒中风险分层工具来帮助决策心房纤颤(AF)患者是否需要使用口服抗凝剂(OAC)。目的探讨初级卫生保健中AF患者利用CHADS2与CHA2DS2VASc进行卒中风险分类的差异;根据卒中风险使用抗血栓制剂的类型;使用OAC的AF患者和诊所的特征。方法对苏格兰315家全科诊所收治的21 564例AF且无风湿性心脏病或瓣膜置换史的患者进行横断面多级建模研究。结果 CHADS2的中度风险为30.3%,高度风险为53.8%,而CHA2DS2VASc的中度风险仅为9.7%,高度风险为85.1%。入选患者中有17.8%未使用抗血栓药,43.3%使用OAC。OAC的使用与卒中风险仅呈弱相关。突发AF、阿尔茨海默病及消化道溃疡患者使用(校正ORs为0.26、0.25和0.79)OAC的概率较小。校正病例组合后诊所使用OAC的情况极为不同,相差达5倍还多,偏远、未经培训及倾向高度风险处方的诊所使用OAC更多。结论已获得的证据表明AF患者同时存在OAC使用不足和使用过度的情况。提倡使用卒中风险评估工具以改善AF管理策略,但仍需通过检验,特别是其对于OAC处方和患者预后的影响仍需通过临床试验进行评估。
Background Current international guidelines advocate the use of stroke risk stratification tools to help determine the need for oral anticoagulation (OAC) in patients with atrial fibrillation (AF). Objectives To investigate the differences in the classification of stroke risk between CHADS2 and CHA2DS2VASc for AF patients in primary health care; the type of antithrombotic agent used according to stroke risk; the characteristics of AF patients and clinics using OAC. METHODS: Twenty-one thousand five hundred and seventy-six patients with AF without rheumatic heart disease or valvular replacement in a total of 315 general hospitals in Scotland were enrolled in this study. Results The median risk of CHADS2 was 30.3% and the high risk was 53.8%, while the moderate risk of CHA2DS2VASc was only 9.7% and the high risk was 85.1%. Among the patients selected, 17.8% did not use antithrombotic drugs and 43.3% used OAC. The use of OAC is only weakly correlated with stroke risk. Patients with sudden AF, Alzheimer’s disease and peptic ulcer patients (adjusted for ORs of 0.26, 0.25, and 0.79) had a lower probability of OAC. The use of OAC in clinics following the combination of the adjusted cases is very different, with more than a five-fold difference, with more OACs being used in clinics that are remote, untrained, and highly risky prescriptions. Conclusions Evidence obtained has shown that both AF patients have underuse and overuse OACs. Advocacy for using stroke risk assessment tools to improve AF management strategies remains to be tested, and in particular its impact on OAC prescription and patient outcomes remains to be assessed through clinical trials.