【medical-news】【资讯翻译】meta分析：华法林使中风风险维持在低水平
发布于 2012-03-30 · 浏览 1809 · IP 天津天津
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http://news.dxy.cn/bbs/topic/8600034
http://www.theheart.org/article/1379875.do
Low rate of residual stroke with warfarin
Cleveland, OH - Patients with nonvalvular atrial fibrillation (AF) currently taking warfarin for stroke prevention can be reassured that their risk for stroke or non-central nervous system (CNS) embolism is low—estimated to be 1.66% annually, say the authors of a meta-analysis using contemporary trial data [1].
Although several new antithrombotic agents have been developed as alternatives to warfarin for stroke prevention in patients with nonvalvular AF, many patients will continue to be treated with warfarin worldwide, at least in the near future, owing to cost considerations, note Dr Shikhar Agarwal (Cleveland Clinic, OH) and colleagues. Physicians may also delay using these newer agents pending more "real-world" data, they say.
The aim of their meta-analysis, published online March 26, 2012 in the Archives of Internal Medicine, was to provide clinicians with contemporary data on the safety and efficacy of warfarin in patients with AF, the authors write.
"When you treat a patient, it's important to understand what the risk is on the best old therapy and then what bang for your buck you get with a new agent," said coauthor Dr Venu Menon (Cleveland Clinic) in a telephone interview. "The important message of our analysis" is that in the current era, a patient who continues with warfarin can expect low event rates.
No hurry to switch
The newer antithrombotic agents are easy to administer, consistent in effect, and largely free of interactions with food and other medications, they note, but they are expensive, which may curb uptake initially.
"Clearly, if you have a new patient who comes in with nonvalvular AF and there is no cost issue, I think one should strongly consider the new agents, because each of them in their individual trials have been proven to be either noninferior or even superior to [warfarin]," Menon said. "But if I have a patient who comes into my clinic with 10 years of being on [warfarin] and happy on it, I don't think there is a significant pressure to change over, because the event rates are quite low," he added.
The coauthors of a linked commentary agree [2]. "Patients who are comfortable with warfarin therapy and whose [time in therapeutic range] is above 75% should be in no hurry to switch," write Dr Daniel E Singer (Massachusetts General Hospital, Boston) and Dr Alan S Go (Kaiser Permanente Northern California, Oakland). "They may forgo a small reduction in risk of intracranial hemorrhage, but they should benefit as we gain more experience with the novel agents. For others, the case for the use of novel anticoagulants may be more compelling, particularly if out-of-pocket costs are acceptable."
The study team pooled data from eight high-quality randomized controlled trials published in the past 10 years that compared warfarin with an alternative thromboprophylaxis strategy. The trials included 32 053 patients, and the pooled analysis yielded 55 789 patient-years of follow-up.
The comparison group for the warfarin arm was ximelagatran in two trials (SPORTIF III and SPORTIF V), and in one trial each, idraparinux (Amadeus), aspirin (BAFTA), aspirin with clopidogrel (ACTIVE W), dabigatran (RE-LY), rivaroxaban (ROCKET-AF), and apixaban (ARISTOTLE).
Warfarin management has evolved
The authors say the estimated pooled annual incidence rate of stroke or non-CNS embolism of 1.66% (95% CI 1.41% -1.91%) is "considerably lower" than the 2.09% in an earlier meta-analysis.
"There has been a significant reduction in the stroke event rate with warfarin treatment during the past two decades," the researchers note. "This reduction may be secondary to considerable improvement in the quality of anticoagulation as reflected by a greater proportion of time spent in therapeutic anticoagulation." In the current meta-analysis, overall time spent in the therapeutic range was 55% to 68%.
However, Menon and colleagues say certain subgroups of patients remain at significantly higher risk for stroke. They are patients aged 75 and older (2.27%), women (2.12%), patients with a prior stroke or transient ischemic attack (TIA) (2.64%), and patients with no previous exposure to vitamin-D antagonists (1.96%). They also noted a significant increase in the annual incidence of stroke with progressively increasing CHADS2 scores.
Besides thromboembolic events, the pooled annual incidence of MI, death, and composite outcomes with warfarin were estimated to be 0.76% (95% CI 0.57%-0.96%), 3.83% (95% CI 3.07%-4.58%) and 4.80% (95% CI 4.22%-5.38%), respectively.
Although there was significant heterogeneity in the definition of bleeding across trials, the incidence of major bleeding episodes ranged from 1.40% to 3.40% per year. The annual rate of intracranial hemorrhage with warfarin ranged from 0.33% to 0.80% per year; the pooled annual event rate was 0.61% (95% CI 0.48%-0.73%).
Menon and colleagues say the large number of patients included in this meta-analysis "increases the strength, validity, and generalizability of the results." The substantial heterogeneity encountered in multiple comparisons is a potential limitation.
In their commentary, Singer and Go say, "We have begun a new, very promising era in preventing stroke in AF. The novel anticoagulants appear to constitute a positive disruptive technology.
"However, warfarin management has also evolved, allowing safe, effective, and inexpensive anticoagulation for many patients with AF, likely slowing the ultimate transition to modern anticoagulant agents."
另外，如使用翻译软件翻译，被发现者扣分1-2分
翻译时参照版规
http://news.dxy.cn/bbs/topic/8600034
http://www.theheart.org/article/1379875.do
Low rate of residual stroke with warfarin
Cleveland, OH - Patients with nonvalvular atrial fibrillation (AF) currently taking warfarin for stroke prevention can be reassured that their risk for stroke or non-central nervous system (CNS) embolism is low—estimated to be 1.66% annually, say the authors of a meta-analysis using contemporary trial data [1].
Although several new antithrombotic agents have been developed as alternatives to warfarin for stroke prevention in patients with nonvalvular AF, many patients will continue to be treated with warfarin worldwide, at least in the near future, owing to cost considerations, note Dr Shikhar Agarwal (Cleveland Clinic, OH) and colleagues. Physicians may also delay using these newer agents pending more "real-world" data, they say.
The aim of their meta-analysis, published online March 26, 2012 in the Archives of Internal Medicine, was to provide clinicians with contemporary data on the safety and efficacy of warfarin in patients with AF, the authors write.
"When you treat a patient, it's important to understand what the risk is on the best old therapy and then what bang for your buck you get with a new agent," said coauthor Dr Venu Menon (Cleveland Clinic) in a telephone interview. "The important message of our analysis" is that in the current era, a patient who continues with warfarin can expect low event rates.
No hurry to switch
The newer antithrombotic agents are easy to administer, consistent in effect, and largely free of interactions with food and other medications, they note, but they are expensive, which may curb uptake initially.
"Clearly, if you have a new patient who comes in with nonvalvular AF and there is no cost issue, I think one should strongly consider the new agents, because each of them in their individual trials have been proven to be either noninferior or even superior to [warfarin]," Menon said. "But if I have a patient who comes into my clinic with 10 years of being on [warfarin] and happy on it, I don't think there is a significant pressure to change over, because the event rates are quite low," he added.
The coauthors of a linked commentary agree [2]. "Patients who are comfortable with warfarin therapy and whose [time in therapeutic range] is above 75% should be in no hurry to switch," write Dr Daniel E Singer (Massachusetts General Hospital, Boston) and Dr Alan S Go (Kaiser Permanente Northern California, Oakland). "They may forgo a small reduction in risk of intracranial hemorrhage, but they should benefit as we gain more experience with the novel agents. For others, the case for the use of novel anticoagulants may be more compelling, particularly if out-of-pocket costs are acceptable."
The study team pooled data from eight high-quality randomized controlled trials published in the past 10 years that compared warfarin with an alternative thromboprophylaxis strategy. The trials included 32 053 patients, and the pooled analysis yielded 55 789 patient-years of follow-up.
The comparison group for the warfarin arm was ximelagatran in two trials (SPORTIF III and SPORTIF V), and in one trial each, idraparinux (Amadeus), aspirin (BAFTA), aspirin with clopidogrel (ACTIVE W), dabigatran (RE-LY), rivaroxaban (ROCKET-AF), and apixaban (ARISTOTLE).
Warfarin management has evolved
The authors say the estimated pooled annual incidence rate of stroke or non-CNS embolism of 1.66% (95% CI 1.41% -1.91%) is "considerably lower" than the 2.09% in an earlier meta-analysis.
"There has been a significant reduction in the stroke event rate with warfarin treatment during the past two decades," the researchers note. "This reduction may be secondary to considerable improvement in the quality of anticoagulation as reflected by a greater proportion of time spent in therapeutic anticoagulation." In the current meta-analysis, overall time spent in the therapeutic range was 55% to 68%.
However, Menon and colleagues say certain subgroups of patients remain at significantly higher risk for stroke. They are patients aged 75 and older (2.27%), women (2.12%), patients with a prior stroke or transient ischemic attack (TIA) (2.64%), and patients with no previous exposure to vitamin-D antagonists (1.96%). They also noted a significant increase in the annual incidence of stroke with progressively increasing CHADS2 scores.
Besides thromboembolic events, the pooled annual incidence of MI, death, and composite outcomes with warfarin were estimated to be 0.76% (95% CI 0.57%-0.96%), 3.83% (95% CI 3.07%-4.58%) and 4.80% (95% CI 4.22%-5.38%), respectively.
Although there was significant heterogeneity in the definition of bleeding across trials, the incidence of major bleeding episodes ranged from 1.40% to 3.40% per year. The annual rate of intracranial hemorrhage with warfarin ranged from 0.33% to 0.80% per year; the pooled annual event rate was 0.61% (95% CI 0.48%-0.73%).
Menon and colleagues say the large number of patients included in this meta-analysis "increases the strength, validity, and generalizability of the results." The substantial heterogeneity encountered in multiple comparisons is a potential limitation.
In their commentary, Singer and Go say, "We have begun a new, very promising era in preventing stroke in AF. The novel anticoagulants appear to constitute a positive disruptive technology.
"However, warfarin management has also evolved, allowing safe, effective, and inexpensive anticoagulation for many patients with AF, likely slowing the ultimate transition to modern anticoagulant agents."
最后编辑于 2022-10-09 · 浏览 1809
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