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1、實証醫學討論會PGY1陳怜文2008.04.0313:001臨床問題Atrialfibrillation容易造成thromboembolism,引起stroke及一些血管栓塞的問題,目前可以使用aspirin或warfarin來預防stroke的發生,使用哪一種預防stroke效果較好?2PICOPatient:AtrialfibrillationIntervention:AnticoagulantComparison:AntiplalettherapyOutcome:lowerriskofstroke3搜尋過程:456

2、Background-atrialfibrillation0.7%generalpopulationPrevalenceincreaseswithageEmbolismofstasis-precipitatedthrombioriginatingintheleftatrialappendageMostcommoncauseofcardioembolicstroke16%ofallischemicstrokesOverallriskofstrokeamongnon-anticoagulatedpatientswithout

3、priorstrokeorTIA:4%peryear7Increasedriskofstrokeinpatient:Age,hypertension,priorTIAorstroke,DM,womanBothoralanticoagulantsandantiplateletagentshaveproveneffectiveforstrokepreventioninmostpatientsathighriskforvasculareventsAspirin:modesteffectAdjusted-dosewarfarin

4、:largereffect,INR:2~3Guideline:Adjusted-dosewarfarinforhighriskforstrokeAspirin:forlowriskorforcannotsafelyreceivedadjusteddosewarfarin8ObjectiveNon-valvularatrialfibrillationandnohistoryofstrokeortransientischemicattack(TIA)OralanticoagulanttreatmentAntiplatelet

5、therapyMajorvascularevents(stroke.MI…)9SearchstrategyCochraneStrokeGroupTrialsRegister(June2006CochraneCentralRegisterofControlledTrials(CENTRAL)(TheCochraneLibraryIssue2,2006)MEDLINE(1966toJune2006)EMBASE(1980toJune2006).AtrialFibrillationCollaborationandexperts

6、workinginthefieldtoidentifyunpublishedandongoingtrials.10SelectioncriteriaRandomizedtrials8randomizedtrials,including9598patientsLong-term(morethan4weeks)Themeanoverallfollowupwas1.9years/participantChronicnon-valvularafpatientsAdjusted-dosewarfarin:INR>1.6Aspiri

7、n:75~325mg/day11OAC:lowerriskofallstroke12OAC:lowerriskofischemicstroke13Substantiallybutnotsignificantly14Substantiallybutnotsignificantly15OAC:lowerriskofsystemicemboli16OAC:Intracranialhemorrhageswereincreased17Similarresult18Similarresult19OAC:lowerrisk20Simi

8、larresult21Mainresults:OralanticoagulantswereassociatedwithlowerriskofAllstrokeIschemicstrokeSystemicemboliSubstantiallybutnotsignificantlyreducedbyoralanticoa