估计维生素K对抗剂对心房患者的抗凝益处,考虑竞争风险:来自12项随机试验的证据
Sachin J Shah1, Carl van Walraven2, Sun Young Jeon3
1Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA (S.J.S., D.E.S.).
Circulation. Cardiovascular quality and outcomes
|March 25, 2024
概括
死亡的竞争风险显著改变了对心房患者抗凝剂益处的估计. 标准的CHA2DS2-VASc模型高估了好处,尤其是对那些预期寿命较短的人来说.
科学领域:
- 心脏病学 心脏病学
- 临床试验 临床试验
- 药理学 药理学是指药理学的学科.
背景情况:
- 心房动 (AF) 患者面临高死亡率,部分来自非血管原因.
- 死亡的竞争风险可以减少抗凝药的感知益处.
- 评估抗凝剂的有效性需要考虑竞争的风险.
研究的目的:
- 评估竞争风险是否对AF患者估计的抗凝剂益处产生重大影响.
- 将指南认可的CHA2DS2-VASc模型与竞争的风险模型进行比较,以估计VKA的好处.
主要方法:
- 对12项随机对照试验的二次分析,涉及AF患者接受VKA治疗,与安慰剂或抗血小板药物对比.
- 使用CHA2DS2-VASc和竞争性风险模型,估计中风/全身血栓塞 VKAs 的绝对风险降低 (ARR).
- 基于不同预期寿命的相对收益估计.
主要成果:
- 与竞争风险模型相比,CHA2DS2-VASc模型高估了VKA的ARR (三年ARR的中位数为6.9%与5.2%).
- 通过CHA2DS2-VASc对益处的高估在预期寿命较低的患者中更为明显.
- 对于最低分位数的预期寿命,3年ARR差异为4.7%;对于最高分位数,它是-1.3%.
结论:
- 维生素K对抗剂 (VKA) 抗凝剂在降低AF中风风险方面非常有效.
- CHA2DS2-VASc模型通过不考虑竞争风险和非线性收益,高估了VKA的好处.
- 福利高估是最大的,与较短的预期寿命和较长的估计时间.
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