Chinese General Practice ›› 2024, Vol. 27 ›› Issue (03): 308-314.DOI: 10.12114/j.issn.1007-9572.2023.0431

Special Issue: 心房颤动最新文章合集

• Original Research • Previous Articles     Next Articles

Influencing Factors of Overanticoagulation at Initial Stage of Warfarin Anticoagulation Therapy in Patients with Atrial Fibrillation

  

  1. 1Department of Pharmacy, Linyi People's Hospital, Linyi 276000, China
    2Department of Pharmacy, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao 266011, China
    3Department of Cardiology, Linyi People's Hospital, Linyi 276000, China
    4Department of Neurology, Aerospace Center Hospital (Peking University Aerospace School of Clinical Medicine), Beijing 100049, China
  • Received:2023-07-21 Revised:2023-08-23 Published:2024-01-20 Online:2023-10-23
  • Contact: WEI Yanjin, QIU Shi

心房颤动患者华法林抗凝治疗初期发生抗凝过度的影响因素研究

  

  1. 1276000 山东省临沂市人民医院药学部
    2266011 山东省青岛市,康复大学青岛医院(青岛市市立医院)药学部
    3276000 山东省临沂市人民医院心血管内科
    4100049 北京市,航天中心医院(北京大学航天临床医学院)神经内科
  • 通讯作者: 魏延津, 邱石
  • 作者简介:
    作者贡献:魏延津提出研究思路,设计研究方案;郭德群、刘存飞负责数据的收集、资料整理与录入;李娇负责数据的统计学处理;范彩霞负责数据分析与结果的解释,撰写论文;李峥嵘负责论文的修订;邱石负责项目的指导和文章的质量控制及审校。
  • 基金资助:
    山东省自然科学基金面上项目(ZR2020MH018); 山东省医药卫生科技发展计划项目(202203011106); 山东省医学会临床科研专项资金-临床药学应用研究项目(YXH2019ZX015); 临沂市科技发展计划项目(202120078)

Abstract:

Background

Atrial fibrillation (AF) is an important risk factor for stroke, cardiovascular disease and all-cause mortality with high prevalence, and appropriate anticoagulant therapy is the core of preventing AF-related stroke. Warfarin is still the main anticoagulant at present, but the therapeutic window of warfarin is narrow, fixed dose of warfarin can easily lead to excessive coagulation or insufficient anticoagulation at the initial stage of treatment. There are few previous clinical studies on overanticoagulation of warfarin.

Objective

To analyze the epidemiological and clinical characteristics of overanticoagulation in patients with AF at the initial stage of warfarin anticoagulation therapy, and explore the influencing factors of overanticoagulation.

Methods

The study was a single-center retrospective cohort study. A total of 552 patients with AF treated with warfarin 2.5 mg/d admitted to Linyi City's Hospital from January 2017 to December 2022 were included as the study subjects. The clinical data of patients were collected, including age, gender, body mass, type of AF (non-valvular/valvular), comorbidities (hypertension, diabetes, hypoproteinemia, transaminase abnormalities, heart failure), combined medication (number of combined drugs, combined antibiotics, combined amiodarone), the laboratory test results before treatment were also collected, including serum albumin (Alb), serum creatinine (Scr), serum alanine aminotransferase (ALT) and serum aspartate aminotransferase (AST) levels, as well as international normalized ratio (INR) before treatment and INR after 7 days of treatment. Patients were divided into the overanticoagulation group (INR>3.0, n=122) and non-overanticoagulation group (INR≤3.0, n=430) according to whether INR>3.0 after 7 days of warfarin therapy. The data of patients between the two groups were compared, univariate and multivariate Logistic regression analysis was used to explore the influencing factors of overanticoagulation in the initial stage of warfarin anticoagulation therapy.

Results

The age, proportion of female, valvular atrial fibrillation, hypoproteinemia, transaminase abnormalities, number of combined drugs, proportion of combined amiodarone and AST of patients in the overanticoagulation group were higher than those in the non-overanticoagulation group, and the body mass, hypertension, diabetes, Alb and ALT were lower than those in the non-overanticoagulation group (P<0.05). Multivariate Logistic regression analysis showed age≥65 years (OR=1.954, 95%CI=1.243-3.073, P=0.004), body mass≤63 kg (OR=2.967, 95%CI=1.841-4.783, P<0.001), number of combined drugs>5 (OR=1.976, 95%CI=1.175-3.323, P=0.010), and Scr≥91 μmol/L (OR=2.087, 95%CI=1.222-3.561, P=0.007) were independent risk factors for overanticoagulation at the initial stage of warfarin anticoagulation in patients with AF, while diabetes (OR=0.424, 95%CI=0.191-0.939, P=0.034) was a protective factor for overanticoagulation at the initial stage of warfarin anticoagulation therapy in patients with AF.

Conclusion

Age≥65 years, body mass≤63 kg, number of combined drugs>5, Scr≥91 μmol/L may be risk factors for overanticoagulation at the initial stage of warfarin anticoagulation therapy in patients with AF, while diabetes may be a protective factor at the initial stage of warfarin anticoagulation therapy in patients with AF. INR should be closely monitored in patients on warfarin anticoagulation with advanced age, low body mass, multiple drug combinations and elevated Scr level.

Key words: Atrial fibrillation, Warfarin, International standard ratio, Overanticoagulation, Risk factors, Logistic model

摘要:

背景

心房颤动发病率高,是引起脑卒中、心血管疾病及全因死亡的重要危险因素,而适当的抗凝治疗是预防心房颤动相关性卒中的核心。华法林仍然是目前主要的抗凝药物,但其治疗窗较窄,固定剂量的华法林在治疗初期很容易导致过度或抗凝治疗不足,既往华法林抗凝过度的临床研究较少。

目的

分析心房颤动患者华法林抗凝治疗初期发生抗凝过度的流行病学和临床特征,并探讨发生抗凝过度的影响因素。

方法

该研究为单中心回顾性队列研究。纳入2017年1月—2022年12月临沂市人民医院收治的行华法林2.5 mg/d治疗的心房颤动患者552例为研究对象,收集患者临床资料,包括年龄、性别、体质量、心房颤动类型(非瓣膜型/瓣膜型)、合并疾病(高血压、糖尿病、低蛋白血症、转氨酶异常、心力衰竭)、联合用药情况(联合用药数量、联用抗菌药物、联用胺碘酮),收集患者治疗前实验室检查结果,包括血清白蛋白(Alb)、血清肌酐(Scr)、血清丙氨酸氨基转移酶(ALT)及血清天门冬氨酸氨基转移酶(AST)水平,收集患者治疗前国际标准化比值(INR)和用药7 d后INR。根据华法林治疗7 d后INR是否>3.0将患者分为抗凝过度组(INR>3.0,n=122)和未抗凝过度组(INR≤3.0,n=430),比较两组患者资料,并采用单因素及多因素Logistic回归分析探究华法林抗凝治疗初期发生抗凝过度的影响因素。

结果

抗凝过度组患者年龄,女性、瓣膜型心房颤动、低蛋白血症、转氨酶异常比例,联合用药数量,联用胺碘酮比例,AST高于未抗凝过度组;体质量、高血压比例、糖尿病比例、Alb、ALT低于未抗凝过度组(P<0.05)。多因素Logistic回归分析结果显示,年龄≥65岁(OR=1.954,95%CI=1.243~3.073,P=0.004)、体质量≤63 kg(OR=2.967,95%CI=1.841~4.783,P<0.001)、联合用药数量>5种(OR=1.976,95%CI=1.175~3.323,P=0.010)、Scr≥91 μmol/L(OR=2.087,95%CI=1.222~3.561,P=0.007)是心房颤动患者华法林抗凝治疗初期发生抗凝过度的独立危险因素,而糖尿病(OR=0.424,95%CI=0.191~0.939,P=0.034)是心房颤动患者华法林抗凝治疗初期发生抗凝过度的保护因素。

结论

年龄≥65岁、体质量≤63 kg、联合用药数量>5种、Scr≥91 μmol/L可能是心房颤动患者华法林抗凝治疗初期发生抗凝过度的危险因素,而糖尿病可能是心房颤动患者华法林抗凝治疗初期发生抗凝过度的保护因素。对于高龄、低体质量、多种药物联合使用、Scr水平升高的华法林抗凝治疗患者应密切监测INR水平。

关键词: 心房颤动, 华法林, 国际标准化比值, 抗凝过度, 危险因素, Logistic模型