Neurology:卒中后长时程心电监护(PCM)提高房颤检出率与抗凝药物应用启动,长期卒中预防获益有待进一步论证!

2022-04-03 Naomi MedSci原创

近日,研究者评估了卒中后长时间心律监测(PCM)与制定卒中预防策略和卒中复发之间的关系。缺血性卒中或短暂性脑缺血发作后的PCM可导致更高的房颤检测率和抗凝剂启动,但尚无RCT证据支持较低卒中复发风险。

卒中后长时间的心律监测(PCM)显示,有相当大比例的缺血性卒中(IS)患者合并心房颤动(AF),传统的心律监测策略没有发现。虽然房颤的发现概率随着心脏监测时间的延长而增加,但对于延长心脏监测在二级卒中预防中的潜在影响和临床益处仍存不确定性。欧洲心脏病学会(ESC)的房颤诊断和处理指南也建议使用长期非侵入性心电监护仪或可插入式心脏监护仪来检测房颤。来自美国卒中协会/美国心脏协会(ASA/AHA),用于预防患有新近IS或短暂性脑缺血发作(TIA)的最新指南提示,对于没有抗凝禁忌症的隐源性卒中患者,长期心律监测是合理的。然而,这两个指南都没有提供关于监测持续时间或要使用的设备类型的任何具体建议。

近日,有研究人员在目前的系统回顾和荟萃分析中,试图通过分析迄今可用的随机对照临床试验(RCT)和观察性研究的数据来评估PCM对二次卒中预防的影响。研究人员还进行了分组和间接分析,以评估不同患者群体和心律监测设备和策略之间的潜在差异。

研究搜索了MEDLINE和Scope us数据库,以确定与接受传统心律监测的患者相比,有近期IS或短暂性脑缺血发作(TIA)接受PCM病史的患者卒中复发率的研究。在随机效应模型下进行配对Meta分析。为了探索监测策略之间的差异,结合了在随机对照试验(RCT)中评估的任何一对监测设备的直接和间接证据。

 

  • 研究共纳入了8项研究(5项随机对照试验,3项观察性研究;2994例患者)。
  • 指数事件后接受PCM治疗的患者在随机对照试验(RR=3.91,95%CI:2.54~6.03;RR=2.16,95%CI:1.66~2.80)和观察性研究(RR=2.06,95%CI:1.57~2.70;RR=2.01;95%CI:1.43~2.83)中,房颤的检出率和抗凝剂启动率均较高。
  • 在观察性研究中,PCM与较低的卒中复发风险相关(RR=0.29;95%CI:0.15~0.59),而在随机对照试验中(RR=0.72,95%CI:0.49~1.07),PCM与卒中复发风险无关。
  • 在RCT的间接分析中,与Holter监护仪和外环记录器相比,植入式环状记录器检测到房颤和启动抗凝的可能性更高。

IS或TIA后的PCM可导致更高的房颤检测率和抗凝剂启动。目前,没有确凿的RCT证据支持PCM可能与较低的卒中复发风险相关。

文献来源:Tsivgoulis, Georgios et al. “Prolonged Cardiac Monitoring and Stroke Recurrence: A Meta-analysis.” Neurology, 10.1212/WNL.0000000000200227. 9 Mar. 2022, doi:10.1212/WNL.0000000000200227

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    2022-12-17 yinhl1978
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    2022-04-01 bioon6

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