Circulation:肾功能不全独立预测房颤卒中风险

2012-12-10 范伟伟 译 Circulation

  近期一项大型、国际多中心研究表明,对于中到高度卒中风险的非瓣膜性房颤患者,肾功能受损是卒中和全身性栓塞的一种强有力预测因素。非瓣膜性房颤患者卒中风险的危险分层中应当包括肾功能。研究于2012年12月3日在线发表于《循环》(Circulation)杂志。   该研究旨在评估卒中发生和系统性栓塞的相关因素。在利伐沙班房颤卒中预防(ROCKET AF)随机双盲研究中,共纳入14264例非

  近期一项大型、国际多中心研究表明,对于中到高度卒中风险的非瓣膜性房颤患者,肾功能受损是卒中和全身性栓塞的一种强有力预测因素。非瓣膜性房颤患者卒中风险的危险分层中应当包括肾功能。研究于2012年12月3日在线发表于《循环》(Circulation)杂志。

  该研究旨在评估卒中发生和系统性栓塞的相关因素。在利伐沙班房颤卒中预防(ROCKET AF)随机双盲研究中,共纳入14264例非瓣膜性房颤和肌酐清除率(CrCl)≥30 mL/min患者随机接受利伐沙班或调整剂量的华法林治疗。采用Cox比例风险模型,以确定在意向性治疗分析的基础上,发生卒中或非中枢神经系统(CNS)栓塞的随机独立相关因素。在ROCKET AF队列中推导风险评分,在ATRIA队列(一个独立的AF组患者队列)中加以验证。

  结果表明,在中位随访时间1.94年期间,575例(4.0%)患者发生主要终点事件。肌酐清除率降低是一个强有力的卒中和全身性栓塞独立预测因素,仅次于既往卒中史或短暂性脑缺血发作(TIA)。与卒中和全身性栓塞相关的其他因素包括舒张压升高和心率,以及心脏和四肢的血管疾病(C-指数为0.635)。一个包括肌酐清除率(R2CHADS2)的模型能够改善净重新分类指数(NRI)6.2%(相比于CHA2DS2VASc,C-统计量= 0.578),和8.2%(相比于CHADS2,C-统计量= 0.575)。一个将估算的肾小球滤过率<60和既往卒中史或短暂性脑缺血发作纳入的模型(没有其他共变量)可使C-统计量达到0.590。在外部的,独立的人群,R2CHADS2的有效性可使NRI相对于CHADS2提高17.4%(95%CI 12.1-22.5%)。


Background
We sought to define the factors associated with the occurrence of stroke and systemic embolism in a large, international atrial fibrillation (AF) trial.
Methods and Results
In ROCKET AF, 14,264 patients with nonvalvular AF and creatinine clearance (CrCl) ≥30 mL/min were randomized to rivaroxaban or dose-adjusted warfarin. Cox proportional hazards modeling was used to identify factors at randomization independently associated with the occurrence of stroke or non-central nervous system (CNS) embolism based on intention-to-treat analysis. A risk score was developed in ROCKET AF and validated in ATRIA, an independent AF patient cohort. Over a median follow-up of 1.94 years, 575 (4.0%) patients experienced primary endpoint events. Reduced CrCl was a strong, independent predictor of stroke and systemic embolism, second only to prior stroke or transient ischemic attack (TIA). Additional factors associated with stroke and systemic embolism included elevated diastolic blood pressure and heart rate, and vascular disease of the heart and limbs (C-index 0.635). A model including CrCl (R2CHADS2) improved net reclassification index (NRI) by 6.2% when compared with CHA2DS2VASc (C-statistic=0.578) and 8.2% when compared with CHADS2 (C-statistic=0.575). The inclusion of estimated glomerular filtration rate <60 and prior stroke or TIA in a model with no other covariates led to a C-statistic of 0.590. Validation of R2CHADS2 in an external, separate population improved NRI by 17.4% (95% CI 12.1-22.5%) relative to CHADS2.
Conclusions
In patients with nonvalvular AF at moderate to high risk of stroke, impaired renal function is a potent predictor of stroke and systemic embolism. Stroke risk stratification in patients with AF should include renal function.

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    2013-01-10 yese
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