房顫是一種常見(jiàn)的心律失常，隨著人口老齡化，房顫的發(fā)病率呈逐年上升趨勢(shì)。腦卒中是房顫主要并發(fā)癥。日前發(fā)表在《柳葉刀 神經(jīng)病學(xué)》的一篇論文數(shù)據(jù)顯示，未接受抗凝治療的房顫患者，每年腦卒中發(fā)病率達(dá)5%，而20%的腦卒中由房顫引起，因此抗凝治療至關(guān)重要。房顫患者發(fā)生腦卒中的風(fēng)險(xiǎn)可通過(guò)CHADS2或CHA2DS2VASs得分來(lái)評(píng)估，經(jīng)抗凝治療后房顫患者發(fā)生腦卒中的機(jī)率降低了三分之二。

    抗凝藥物維生素K拮抗劑，如華法林在臨床上并未得到充分利用。新型口服抗凝劑如凝血酶抑制劑達(dá)比加群、Xa因子抑制劑利伐沙班和阿哌沙班，它們和華法林一樣有效。研究顯示，達(dá)比加群預(yù)防腦卒中的作用優(yōu)于華法林，出血發(fā)生幾率與之相當(dāng)，顱內(nèi)出血較華法林顯著降低。利伐沙班至治療效果也與華法林相當(dāng)。不足之處是可能需要迅速有效的止血?jiǎng)?，必須精確監(jiān)測(cè)血漿濃度以了解抗凝效應(yīng)，胃腸道也有一定程度的出血風(fēng)險(xiǎn)，同時(shí)它們的價(jià)格比華法林貴。

    新型口服抗凝藥可降低房顫患者的中風(fēng)風(fēng)險(xiǎn)。臨床上應(yīng)重視非瓣膜性房顫患者的風(fēng)險(xiǎn)評(píng)分，積極進(jìn)行抗凝治療。

    Antithrombotic therapy for stroke prevention in non-valvular atrial fibrillation

    Prof Mark J Alberts MD, John W Eikelboom FRACP, Prof Graeme J Hankey MD

    Summary

    The world faces an epidemic of atrial fibrillation and atrial fibrillation-related stroke. An individual's risk of atrial fibrillation-related stroke can be estimated with the CHADS2 or CHA2DS2VASc scores, and reduced by two-thirds with effective anticoagulation. Vitamin K antagonists, such as warfarin, are underused and often poorly managed. The direct thrombin inhibitor dabigatran etexilate and factor Xa inhibitors rivaroxaban and apixaban are new oral anticoagulants that are at least as efficacious and safe as warfarin. Their advantages are predictable anticoagulant effects, low propensity for drug interactions, and lower rates of intracranial haemorrhage than with warfarin. A disadvantage is the continuing need to develop and validate rapidly effective antidotes for major bleeding and standardised tests that accurately measure plasma concentrations and anticoagulant effects, together with the disadvantage of possible higher rates of gastrointestinal haemorrhage and greater expense than with warfarin. The new oral anticoagulants should increase the number of patients with atrial fibrillation at risk of stroke who are optimally anticoagulated, and reduce the burden of atrial fibrillation-related stroke.