查看更多>>摘要：目的 探究真实世界心房颤动（房颤）合并急性冠脉综合征（ACS）人群的抗栓策略变迁及其对心血管不良事件的影响。 方法 本研究为单中心、前瞻性、观察性研究。选取2017—2019年于中国医学科学院阜外医院就诊的房颤合并ACS患者，根据抗栓策略分为抗凝治疗组与未抗凝治疗组，根据就诊时间将研究人群分为2017年组、2018年组、2019年组。对所有患者开展1年随访，主要终点为心源性卒中，次要研究终点为随访1年内发生主要不良心血管事件（MACCE），定义为全因死亡、心源性卒中、非中枢神经系统的体循环栓塞、心肌梗死、靶血管血运重建、缺血驱动的血运重建。 结果 共入选1 333例房颤合并ACS患者，其中男922例，年龄（68.3±9.7）岁。其中接受抗凝治疗患者534例（抗凝治疗组），未接受抗凝治疗患者799例（未抗凝治疗组）。与未抗凝治疗组相比，抗凝治疗组患者的CHA2DS2-VASc评分更高[（3.7±1.9）分对（4.3±1.8）分，P<0.001]。2017—2019年，接受抗凝治疗（P<0.001，P for trend<0.001）、口服抗凝药（OAC）+单药抗血小板治疗（SAPT）双联抗栓治疗（P=0.018，P for trend=0.006）以及OAC+双联抗血小板治疗（DAPT）三联抗栓治疗（P<0.001，P for trend<0.001）的比例均逐年增加。主要终点方面，未抗凝治疗组1年内发生心源性卒中5例（0.6%，5/799），抗凝治疗组1年内发生心源性卒中19例（3.6%，19/534），Log-rank检验提示两者差异有统计学意义（P<0.001）。2017年组发生心源性卒中10例（2.3%，10/429），2018年组发生心源性卒中9例（1.6%，9/573），2019年组发生心源性卒中5例（1.5%，5/331），Log-rank检验提示3者差异无统计学意义（P=0.604）。次要终点方面，未抗凝治疗组1年内发生MACCE事件75例（9.4%，75/799），抗凝治疗组1年内发生心源性卒中85例（15.9%，85/534），Log-rank检验提示差异存在统计学意义（P<0.001）。2017年组发生MACCE事件48例（11.2%，48/429），2018年组发生MACCE事件72例（12.6%，72/573），2019年组发生MACCE事件40例（12.1%，40/331），Log-rank检验提示3者差异无统计学意义（P=0.827）。 结论 在真实世界中，房颤合并ACS患者的抗凝治疗与联合抗栓治疗呈现逐年上升趋势，但心源性卒中及MACCE事件发生率未见明显改善，这可能与抗凝组CHA2DS2-VASc评分更高有关。未来应重点关注这一特殊人群的综合防控，并采取更加积极合理的抗栓策略。 Objective To analyze the antithrombotic strategies in patients with atrial fibrillation (AF) combined with acute coronary syndrome (ACS), and their adverse cardiovascular events in real-world practice. Methods This research was a single-center, prospective, observational study. The patients with AF combined with ACS from Chinese Academy of Medical Sciences Fuwai Hospital between 2017 and 2019 were selected, and were divided into anticoagulant therapy and non-anticoagulant therapy groups by physician′ experience and patients′ intention, and were also divided into 2017, 2018, and 2019 groups according to the time of consultation. One year follow-up was conducted for all patients, with the primary endpoint of cardiogenic stroke. The secondary study endpoint was defined as major adverse cardiovascular events (MACCE), including all-cause death, cardiogenic stroke, non-central nervous system embolism of the corpuscular circulation, myocardial infarction, target vessel revascularization, and ischemia-driven revascularization. Results A total of 1 333 patients with AF combined with ACS were enrolled in this study. Nine hundred and twenty-two patients were male, the average age was 68.3±9.7. Among them, 534 patients received anticoagulation therapy, and 799 patients did not receive anticoagulation therapy. Compared with non-anticoagulant group, anticoagulant group had higher CHA2DS2-VASc score (3.7±1.9 vs. 4.3±1.8, P<0.001). Between 2017 and 2019, patients who received anticoagulation (P<0.001,P for trend<0.001), dual antithrombotic therapy with oral anticoagulants (OAC) +single antiplatelet therapy (SAPT,P=0.018, P fort rend=0.006), and triple antithrombotic therapy with OAC+dual antiplatelet therapy (DAPT, P<0.001,P for trend<0.001) increased by years. In terms of primary endpoint, cardiogenic stroke occurred in 5 patients (0.6%, 5/799) in the non-anticoagulant group, and 19 patients (3.6%, 19/534) in the anticoagulant group. Log-rank test indicated that the difference was statistically significant (P<0.001). Cardiogenic stroke occurred in 10 patients (2.3%, 10/429) in the 2017 group, 9 patients (1.6%, 9/573) in the 2018 group, and 5 patients (1.5%, 5/331) in the 2019 group. Log-rank test indicated that there was no statistical significance between the three groups (P=0.604). In terms of secondary endpoints, 75 cases (9.4%, 75/799) of MACCE events occurred in the non-anticoagulant treatment group while 85 cases (15.9%, 85/534) occurred in the anticoagulant treatment group. Log-rank test indicated statistically significant differences (P<0.001). There were 48 MACCE events in the 2017 group (11.2%, 48/429), 72 MACCE events in the 2018 group (12.6%, 72/573), and 40 MACCE events in the 2019 group (12.1%, 40/331). Log-rank test showed no statistical significance (P=0.827) . Conclusion In recent years, anticoagulation and combined antithrombotic therapy in patients with AF combined with ACS showed an increasing trend year by year, but the incidence of cardiogenic stroke and MACCE did not improve significantly, which may be related to the higher CHA2DS2-VASc score in the anticoagulation group. Future studies should focus on comprehensive managements in this special population, and adopt more active and reasonable anti-thrombotic strategies.
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