老年瓣膜型心房颤动病人华法林抗凝过度危险因素分析

doi:10.3969/j.issn.1003-9198.2025.07.010

摘要/Abstract

摘要： 目的分析老年瓣膜型心房颤动病人华法林抗凝过度的危险因素。方法选择2022年3月至2024年5月接受华法林治疗的235例老年瓣膜型心房颤动病人,根据治疗7 d后国际标准化比值(INR)评估是否发生抗凝过度,分为过度组与非过度组。比较2组临床资料,并分析抗凝过度的危险因素以及各危险因素对老年瓣膜型心房颤动病人抗凝过度的预测价值。结果 235例病人中,抗凝过度发生率为22.98%(54/235)。过度组年龄≥80岁、合并低蛋白血症、联用胺碘酮的比例,联合用药种数,入院时血肌酐、AST水平,初始华法林剂量高于非过度组,ALT水平、体质量、合并糖尿病比例低于非过度组(P＜0.05)。Logistic回归分析结果显示,年龄≥80岁(OR=3.991,95%CI:1.754~9.078)、AST(OR=4.764,95%CI:2.094~10.836)、联合用药种数(OR=4.170,95%CI:1.833~9.487)为老年瓣膜型心房颤动病人发生抗凝过度的独立危险因素,体质量(OR=0.277,95%CI:0.122~0.630)为抗凝过度的保护因素。年龄≥80岁、AST、联合用药种数、体质量及联合模型预测老年瓣膜型心房颤动病人发生抗凝过度的AUC分别为0.656、0.885、0.792、0.691、0.978(P＜0.05)。结论年龄较高、入院时AST水平较高、联合用药种数较多、体质量较低的老年瓣膜型心房颤动病人发生华法林抗凝过度的风险较高,制订针对性应对策略可有助于降低老年瓣膜型心房颤动病人抗凝过度的发生风险。

关键词: 老年人, 瓣膜型心房颤动, 华法林, 抗凝过度, 危险因素

Abstract: Objective To analyze the risk factors of over-anticoagulation with warfarin in the elderly patients with valvular atrial fibrillation. Methods A total of 235 elderly patients with valvular atrial fibrillation who were treated with warfarin from March 2022 to May 2024 were selected. According to the international standardized ratio (INR) after 7 days of treatment, the patients were divided into over-anticoagulation group and normal anticoagulation group. The clinical data of the two groups were compared, and the risk factors of over-anticoagulation in the elderly patients with valvular atrial fibrillation were analyzed. The predictive value of the risk factors for over-anticoagulation was analyzed. Results Among 235 patients, the incidence rate of over-anticoagulation was 22.98% (54/235). The proportion of the patients aged 80 years or older, combined with hypoproteinemia, and combined with amiodarone, the number of combined medication, the levels of creatinine and aspartate aminotransferase (AST), and initial warfarin dose at admission in the over-anticoagulation group were higher than those in the normal anticoagulation group, and the level of alanine aminotransferase (ALT), the body mass and the proportion of diabetes mellitus were lower than those in the normal anticoagulation group (P<0.05). Logistic regression analysis showed that age ≥80 years (OR=3.991, 95%CI: 1.754-9.078), the level of AST at admission (OR=4.764, 95%CI: 2.094-10.836), the number of combination medication (OR=4.170, 95%CI: 1.833-9.487) were independent risk factors, and body mass (OR=0.277, 95%CI: 0.122-0.630) was the protective factor for over-anticoagulation in the elderly patients with valvular atrial fibrillation. The area under the receiver operating characteristic curve of age ≥80 years, AST at admission, the number of combined medication, body mass and combined model in predicting over-anticoagulation was 0.656, 0.885, 0.792, 0.691 and 0.978, respectively (P<0.05). Conclusions The elderly patients with valvular atrial fibrillation who have older age, higher AST level at admission, higher number of combined medication, and lower body mass have a higher risk of over-anticoagulation with warfarin. The development of targeted management strategies can help to reduce the risk of over-anticoagulation in the elderly patients with valvular atrial fibrillation.

Key words: aged, valvular atrial fibrillation, warfarin, over-anticoagulation, risk factors

中图分类号:

R541.

孙鲁生, 张丽芳, 高俊杰, 汤秀英. 老年瓣膜型心房颤动病人华法林抗凝过度危险因素分析[J]. 实用老年医学, 2025, 39(7): 698-702.

SUN Lusheng, ZHANG Lifang, GAO Junjie, TANG Xiuying. Analysis of risk factors for over-anticoagulation with warfarin in elderly patients with valvular atrial fibrillation[J]. Practical Geriatrics, 2025, 39(7): 698-702.

参考文献

[1] GUROL M E, SPOSATO L A. Advances in neurocardiology: focus on anticoagulation for valvular heart disease with and without atrial fibrillation[J]. Stroke, 2022, 53(12): 3763-3768.
[2] 郭炯超, 黄雅婷, 付敏敏, 等. 中性粒细胞和高密度脂蛋白胆固醇及脂蛋白(a)与老年心房颤动患者合并脑卒中的相关性[J]. 中华老年心脑血管病杂志, 2024, 26(6): 657-660.
[3] LAWAL O D, ARONOW H D, SHOBAYO F, et al. Comparative effectiveness and safety of direct oral anticoagulants and warfarin in patients with atrial fibrillation and chronic liver disease: a nationwide cohort study[J]. Circulation, 2023, 147(10): 782-794.
[4] 任艳霞, 安智晶, 张得梅, 等. 左心耳封堵术与口服抗凝药物应用于心房颤动患者有效性及安全性的meta分析[J]. 上海交通大学学报(医学版), 2021, 41(5): 642-647.
[5] 刘沈馨雨, 孙国珍, 王洁. 心房颤动患者抗凝治疗体验质性研究的Meta整合[J]. 护理学报, 2021, 28(21): 1-6.
[6] 中华医学会心电生理和起搏分会, 中国医师协会心律学专业委员会, 中国房颤中心联盟心房颤动防治专家工作委员会. 心房颤动: 目前的认识和治疗建议(2021)[J]. 中华心律失常学杂志, 2022, 26(1): 15-88.
[7] 范彩霞, 郭德群, 李峥嵘, 等. 华法林与胺碘酮联用致抗凝过度引起华法林相关肾病[J]. 药物不良反应杂志, 2024, 26(5): 318-320.
[8] 范彩霞, 李娇, 魏延津, 等. 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[J]. 中国全科医学, 2024, 27(3): 308-314.
[9] 中华医学会心血管病学分会, 中国老年学学会心脑血管病专业委员会. 华法林抗凝治疗的中国专家共识[J]. 中华内科杂志, 2013, 52(1): 76-82.
[10] 司在霞. 机械瓣膜置换术后出院患者服用华法林依从性及其预测因素研究[D]. 济南: 山东大学, 2013.
[11] 刘文启, 刘洁, 李峥嵘, 等. 医师-临床药师协作抗凝管理服务在瓣膜病型心房颤动患者中的应用[J]. 中华全科医师杂志, 2018, 17(12): 997-1001.
[12] SHENDRE A, PARMAR G M, DILLON C, et al. Influence of age on warfarin dose, anticoagulation control, and risk of hemorrhage[J]. Pharmacotherapy, 2018, 38(6): 588-596.
[13] ANTHONY C J, KARIM S, ACKROYD-STOLARZ S, et al. Intensity of anticoagulation with warfarin and risk of adverse events in patients presenting to the emergency department[J]. Ann Pharmacother, 2011, 45(7/8): 881-887.
[14] 郭德群, 柳波, 单淑萍, 等. 早期国际标准化比值对老年心房颤动患者华法林抗凝过度的预测价值[J]. 中华老年医学杂志, 2023, 42(7): 766-771.
[15] 李波霞. 基因与临床因素对心脏瓣膜置换术后患者抗凝治疗的影响研究[D]. 兰州: 兰州大学, 2020.
[16] ZHANG Y, XIE C, XUE L, et al. A post-hoc interpretable ensemble model to feature effect analysis in warfarin dose prediction for Chinese patients[J]. IEEE J Biomed Health Inform, 2022, 26(2): 840-851.
[17] 李楠. 抗凝药物的安全性研究[D]. 北京: 北京协和医学院, 2019.
[18] 姚慧娟, 李平, 刘昕竹, 等. 药学门诊患者服用华法林随访分析[J]. 医药导报, 2019, 38(10): 1359-1362.
[19] LEISS W, MÉAN M, LIMACHER A, et al. Polypharmacy is associated with an increased risk of bleeding in elderly patients with venous thromboembolism[J]. J Gen Intern Med, 2015, 30(1): 17-24.
[20] 刘佳, 李晓琪, 王绪云, 等. 体质量指数与基因型交互作用对华法林稳定治疗剂量的影响[J]. 中华老年多器官疾病杂志, 2016, 15(1): 1-5.
[21] 宋志花, 姚菁, 魏新萍, 等. “四位一体” 管理模式在社区老年慢性非瓣膜性房颤患者抗凝治疗中的应用[J]. 中国临床医学, 2020, 27(3): 477-480.
[22] 任建国, 孙玉景, 陈照家, 等. 严格控制饮食中维生素K摄入量对应用华法林治疗急性肺栓塞患者的疗效[J]. 中国老年学杂志, 2019, 39(24): 5976-5978.