壹生资讯-房颤患者血管内治疗后早期抗凝的疗效和安全性研究

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房颤患者血管内治疗后早期抗凝的疗效和安全性研究

2023-04-23作者：论坛报沐雨资讯

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Stroke & Vascular Neurology（SVN）最新上线文章“Efficacy and safety of early anticoagulation after endovascular treatment in patients with atrial fibrillation”，来自中国人民解放军陆军特色医学中心（大坪医院）神经内科张猛教授团队。

血管内治疗（endovascular treatment, EVT）后血管再通的急性缺血性卒中（acute ischaemic stroke, AIS）伴房颤患者启动抗凝治疗的时机尚不明确。本研究旨在评估伴有房颤的AIS患者成功再通后早期抗凝治疗的效果。

研究团队对急重症缺血性卒中血管再通治疗后监测与管理的队列研究（Registration Study for Critical Care of Acute Ischemic Stroke after Recanalization, RESCUE-RE）中急性缺血性卒中后24小时内经EVT成功再通的前循环大血管闭塞合并房颤患者进行了分析。早期抗凝定义为EVT后72小时内开始使用普通肝素（unfractionated heparin, UFH）或低分子量肝素（low-molecular-weight heparin, LMWH）。如果在24小时内启动，则定义为超早期抗凝。主要疗效结局为第90天改良Rankin量表（modified Rankin Scale, mRS），主要安全性结局为90天内出现症状性颅内出血。

Figure 1. Flowchart. ASPECTS, Alberta Stroke Programme Early CT Score; EVT, endovascular treatment; ICH, intracranial haemorrhage; mRS, modified Rankin Scale; mTICI, modified Thrombolysis In Cerebral Infarction; NIHSS, National Institutes of Health Stroke Scale; RESCUE-RE, Registration Study for Critical Care of Acute Ischemic Stroke after Recanalization.

研究共纳入257例患者，其中141例（54.9%）在EVT后72小时内开始抗凝，111例在24小时内开始抗凝。第90天时mRS评分显著改善与早期抗凝治疗相关（校正后common OR 2.08, 95%CI 1.27-3.41）。症状性颅内出血在接受早期和常规抗凝治疗的患者之间具有可比性（校正后OR 0.20, 95%CI 0.02-2.18）。通过比较不同的早期抗凝方案表明，超早期抗凝与良好的功能结局（校正后common OR 2.03, 95%CI 1.20-3.44）更显著相关，并可降低无症状性颅内出血的发生率（OR 0.37, 95%CI 0.14-0.94）。

Figure 2. Distribution of modified Rankin Scale (mRS) scores at 90 days for patients allocated to early and routine anticoagulation group (adjusted common OR 2.08 (95% CI 1.27 to 3.41)).

Figure 3. Subgroup analysis. The forest plot displays effect variation across six subgroups for the functional independence at 90 days. The adjusted OR was calculated by using logistic regression and adjusted for age, history of hypertension, baseline NIHSS, baseline glucose level, baseline ASPECTS, treatment with intravenous thrombolysis, heparin during procedure and onset to reperfusion time. The thresholds for age, baseline NIHSS Score, baseline ASPECTS and onset to reperfusion time were chosen at the median. ASPECTS, Alberta Stroke Programme early CT Score; ICA, internal carotid artery; MCA-M1/M2, the first/second segment of middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale.

Figure 4. Outcomes in different early anticoagulation regimens. *No patients in the 24–72-hour anticoagulation group died within 90 days, so this OR could not be available. aICH, asymptomatic intracranial haemorrhage; LMWH, low-molecular-weight heparin, mRS, modified Rankin Scale; NA, not available; sICH, symptomatic intracranial haemorrhage, UFH, unfractionated heparin.

基于以上研究结果，可得出结论，在伴有房颤的AIS患者中，成功再通后早期使用UFH或LMWH进行抗凝治疗与良好的功能结局相关，且不会增加症状性颅内出血风险。

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