| [Background]Atrial fibrillation(AF)is one of the most common arrhythmias in clinical practice.It has the characteristics of high morbidity,high mortality and high disability rate.Its main harm is stroke and thromboembolism.Domestic and foreign guidelines recommend anticoagulant therapy for non-valvular patients with atrial fibrillation at high risk of stroke.However,current research shows that there is still a big gap between real-world anticoagulant therapy and guideline recommendations,and there are insufficient and unreasonable anticoagulant therapy.The current status and influencing factors of anticoagulation treatment for non-valvular atrial fibrillation in Yunnan area are still unclear,and there is a lack of real data on anticoagulant treatment in Yunnan area.[Objective]To investigate the current status of anticoagulant therapy in patients with non-valvular atrial fibrillation in some areas of Yunnan,and analyze the factors affecting anticoagulant therapy.[Methods]This study is a single center,prospective,observational study.199 patients with non-valvular atrial fibrillation were enrolled,which CHA2DS2-VASc score≥2,from the Department of Cardiology,the First Affiliated Hospital of Kunming Medical University from June 2019 to October 2020.Collect information such as baseline data,laboratory examinations,echocardiography,medication and surgical treatment,anticoagulation treatment,medication compliance score and other information during hospitalization.All patients were followed up by telephone at 3 and 6 months after discharge,asking them whether they would continue anticoagulation and collecting the use of anticoagulant drugs in anticoagulant patients,collecting information on strokes,bleeding events,rehospitalization and death,and analyzing them factors affecting anticoagulant therapy.[Results]1.In the selected 199 patients with non-valvular atrial fibrillation,5 patients were lost to follow-up at 3 months,7 patients were lost to follow-up at June,and 13 cases were lost to follow-up.The total loss to follow-up rate was 6.5%.2.Baseline data of patients with non-valvular atrial fibrillation:The average age of the patients was 67.65±9.63 years old,and the average length of stay was 8.9±4.0 days,of which 58.3%(116/199)were men and 59.8%(119/199)were persistent atrial fibrillation.The main comorbid diseases are:hypertension 75.9%(151/199),heart failure 52.8%(105/199),diabetes 25.1%(50/199),coronary heart disease 25.6%(51/199),stroke 22.6%(45/199).3.The proportion of anticoagulation treatment in patients with non-valvular atrial fibrillation:the proportion of anticoagulation before hospitalization was 30.1%(61/199),the proportion of anticoagulation at discharge was 82.4%(164/199),and the proportion of non-anticoagulation was 17.6%(35/199),including 11.1%(22/199)of single antiplatelet therapy.Five patients were lost to follow-up 3 months after discharge,and six died.Among the 188 patients who were followed up,the proportion of continued anticoagulation was 67.0%(126/188),and the proportion of non-anticoagulation was 33.0%(62/188),including single antiplatelet therapy 12.8%(24/188).A total of 13 cases were lost to follow-up 6 months after discharge,and 17 cases died.Among the 169 patients who were followed up,the proportion of continued anti coagulation was 47.3%(80/169),and the proportion of non-anticoagulation was 52.7%(89/169),including single anticoagulation.Platelet therapy was 17.2%(29/169).4.The use of anticoagulants in patients with non-valvular atrial fibrillation:81.7%(134/164)of the patients who used anticoagulants at discharge used NOAC[rivaroxaban 64.9%(87/134),dabigatran 35.1%(47/134)],18.3%(30/164)used warfarin.Among them,the dosage of rivaroxaban from low to high is:2.3%(2/87)2.5 mg/day,1.1%(1/87)5 mg/day,and 37.9%(33/87)10 mg/day,44.8%(39/87)is 15mg/day,13.9%(12/87)is 20mg/day;the dose of dabigatran in descending order is:6.4%(3/47)is 110mg/day,76.6%(36/47)was 220 mg/day,17.0%(8/47)was 300 mg/day;only 23.3%(7/30)of the patients using warfarin met the INR standard.3 months after discharge,79.4%(100/126)of the patients who used anticoagulant drugs used NOAC[rivaroxaban 63%(63/100),dabigatran 37%(37/100)],20.6%(26/126)Use warfarin.76.3%(61/80)of patients who used anticoagulant drugs.6 months after discharge from the hospital used NOAC[rivaroxaban 68.9%(42/61),dabigatran 31.1%(19/61)],23.7%(19/60)Use warfarin.5.During an average follow-up of 6 months,the deaths,strokes,bleeding and rehospitalization of patients with non-valvular atrial fibrillation were as follows:17 patients died[9.1%(17/186)],and the cause of death was heart failure[41.2%(7/17)],cause of death unknown[29.4%(5/17)],ischemic stroke[17.6%(3/17)],malignant tumor[11.8%(2/17)].Stroke occurred in 6 patients[3.2%(6/186)],of which 5 had cerebral infarction,1 had cerebral hemorrhage,and 2 patients were disabled due to stroke.The specific conditions of 6 patients with stroke are as follows:patients with cerebral hemorrhage took 15 mg of rivaroxaban per day for a long time;3 patients had cerebral infarction after discontinuing anticoagulants after discharge,and 1 patient had cerebral infarction 2 days after discharge(taking rivaroxaban).Shaban 15 mg/day),one case had cerebral infarction during the medication(dabigatran 110 mg/day).Bleeding events occurred in 26 patients[15.1%(26/186)],of which 1 case was cerebral hemorrhage,10 cases were melena(5 cases were hospitalized for this reason),6 cases were petechiae of skin and mucous membranes,and 5 cases were Gum bleeding,1 case was postoperative wound bleeding,1 case was conjunctival bleeding,1 case was epistaxis,1 case was hematuria.44 patients were rehospitalized[23.7%(44/186)],of which 10 patients were hospitalized more than twice.Reasons for hospitalization from high to low are:heart failure[38.7%(17/44)],atrial fibrillation[18.2%(8/44)],stroke[13.6%(6/44)],gastrointestinal hemorrhage[11.4%(5/44)],coronary artery disease[6.8%(3/44)],respiratory tract infection[4.5%(2/44)],surgery[4.5%(2/44)],digestive tract disease[2.3%(1/44)].6.Comparison of clinical characteristics between anticoagulation group and non-anticoagulation group:at discharge,compared with the non-anticoagulation group,atrial fibrillation ablation in the anti coagulation group(34.1%vs.8.6%,P=0.003),stroke history(25.6%)vs.8.6%,P=0.029),and the medication compliance score is high(6.32±1.36 vs.5.54±1.12,P=0.002),while PCI(13.4%vs.40.0%,P<0.001),antiplatelet therapy(12.8%vs.62.9%,P<0.001)the proportion is low.Three months after discharge,compared with the non-anticoagulation group,the anticoagulation group had a higher ablation rate(36.5%vs.20.9%,P=0.031)and a higher medication compliance score(6.62± 1.10 vs.5.27± 1.46,P<0.001),While the proportion of coronary heart disease(20.6%vs.35.5%,P=0.028),PCI(15.1%vs.27.4%,P=0.043),and antiplatelet therapy(11.1%vs.43.5%,P<0.001)was low.Six months after discharge,compared with the non-anticoagulation group,the ratio of left atrial appendage occlusion(3.8%vs.23.6%,P<0.001)and antiplatelet therapy(15.0%vs.29.2%,P=0.027)in the anticoagulation treatment group was higher than that in the non-anticoagulation group.The score was low,and the medication compliance score was high(6.78± 1.12 vs.5.91±1.32,P<0.001).7.Logistic multivariate regression analysis of anticoagulation therapy in patients with non-valvular atrial fibrillation:At discharge,stroke history(OR=7.081,95%CI 1.157～43.326,P=0.034)is a predictive factor for patients with anticoagulation therapy.PCI(OR=0.067,95%CI 0.006～0.735,P=0.027),antiplatelet therapy(OR=0.074,95%CI 0.018～0.309,P<0.001),low medication compliance(OR=0.049,95%CI 0.007～0.36,P=0.003)is a predictive factor for patients without anticoagulant therapy.Three months after discharge from the hospital,antiplatelet therapy(OR=0.097,95%CI 0.027～0.354,P<0.001)and low medication compliance(OR=0.037,95%CI 0.01～0.137,P<0.001)means that the patient is not anticoagulant Predictive factors.Six months after discharge,the CHA2DS2-VASc score was high(OR=1.742,95%CI 1.122～2.706,P=0.013)as a predictor of anticoagulant therapy.Left atrial appendage occlusion(OR=0.081,95%CI 0.019～0.336,P=0.001),antiplatelet therapy(OR=0.227,95%CI 0.08～0.641,P=0.005),moderate medication compliance(OR=0.28,95%CI 0.107～0.731,P=0.009),low(OR=0.131,95%CI 0.044～-0.384,P<0.001)are the predictors of non-anticoagulation.8.The main reasons why patients with non-valvular atrial fibrillation do not anticoagulate:at the time of discharge,after PCI[28.6%(10/35)],patients are relatively contraindicated[17.1%(6/35)],and patients refuse[11.4%(4/35)],after pacemaker[14.3%(5/35)],after atrial fibrillation catheter ablation[8.6%(3/35)],doctor without prescription[11.4%(4/35)],Antiplatelet therapy[8.6%(3/35)]is the reason why the patient does not anticoagulate.After 3 and 6 months of discharge,antiplatelet therapy[25.5%(16/62),31.5%(28/89)],atrial fibrillation catheter ablation[16.1%(10/62),20.2%(18/89))],poor compliance[19.4%(12/62),15.7%(14/89)],bleeding concerns,bleeding events,expensive drugs,inconvenience in purchasing drugs,and ignorance of the condition are the main reasons why patients do not anticoagulate.[Conclusion]1.Non-valvular atrial fibrillation patients with high risk of stroke in some parts of Yunnan Province have a higher proportion of anticoagulation treatment when they are discharged from the hospital,and the proportion of anticoagulation treatment decreases significantly after discharge,and the proportion of anticoagulation treatment after 6 months of discharge is less than half.The proportion of new oral anticoagulants used is higher than that of warfarin,but the persistence is not as good as warfarin.The dosage of the new oral anticoagulant has not completely reached the recommended dosage of the guideline.The results of the study suggest that patients with non-valvular atrial fibrillation in Yunnan Province have insufficient and unreasonable anticoagulation,which is far from the guidelines recommended,and there is an urgent need to improve the current status of anticoagulation therapy.2.The main reasons why patients with non-valvular atrial fibrillation are not treated with anticoagulation are antiplatelet therapy,atrial fibrillation catheter ablation surgery,poor compliance,bleeding events,bleeding concerns,expensive drugs,inconvenient drug purchases,and lack of understanding of the condition.The doctor has not prescribed a prescription.PCI,antiplatelet therapy,and low medication compliance are predictive factors for patients not to anticoagulant therapy.3.Strengthen the training of clinicians on atrial fibrillation anticoagulation related guidelines,as well as the education and management of patients with non-valvular atrial fibrillation to improve compliance with anticoagulation therapy.In addition,health management departments,medical insurance departments and the government should increase investment to improve the current status of anticoagulation treatment for patients with non-valvular atrial fibrillation in Yunnan Province. |
PDF Full Text Request