Фибрилляция предсердий как фактор риска ишемического инсульта

Гиляров М.Ю., Константинова Е.В. Фибрилляция предсердий как фактор риска ишемического инсульта. Consilium Medicum. 2015; 17 (9): 16–19. DOI: 10.26442/2075-1753_2015.9.16-20

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Gilyarov M.Yu., Konstantinova E.V. Atrial fibrillation as a risk factor for ischemic stroke. Consilium Medicum. 2015; 17 (9): 16–19. DOI: 10.26442/2075-1753_2015.9.16-20

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Аннотация

Фибрилляция предсердий (ФП) – широко распространенное нарушение ритма сердца, встречаемость которого в общей популяции составляет 1–2%. ФП повышает для больного риск развития ишемического инсульта в 5–7 раз независимо от ее формы (пароксизмальная, постоянная или персистирующая). Для снижения риска развития инсульта применяется пероральная антикоагулянтная терапия (АКТ), которая до недавнего времени ограничивалась препаратами группы антагонистов витамина К (АВК), лидирующая позиция среди которых принадлежит варфарину. Особенности проведения терапии варфарином стимулировали появление новых пероральных антикоагулянтов (НПОАК): апиксабана, дабигатрана этексилата, ривароксабана и эдоксабана. Результаты клинических исследований показали, что НПОАК у лиц с неклапанной ФП не уступают варфарину по эффективности и безопаснее по частоте развития внутричерепных кровотечений. Решение о назначении АКТ зависит от соотношения рисков развития инсульта и кровотечений, которые рассчитываются с помощью клинических шкал CHA₂DS₂-VASc и HAS-BLED. Согласно Российским и Европейским рекомендациям НПОАК являются альтернативой назначения варфарина у пациентов с неклапанной ФП. Имплантация окклюзирующих устройств в ушко левого предсердия в настоящее время показана больным с противопоказаниями к длительной АКТ. Анализ данных клинических исследований и рекомендаций по ведению пациентов с ФП позволяет принять оптимальное решение по назначению эффективной, безопасной и экономически целесообразной терапии для каждого пациента.

Ключевые слова: фибрилляция предсердий, ишемический инсульт, варфарин, новые пероральные антиокагулянты, клинические исследования, факторы риска, CHA₂DS₂-VASc, HAS-BLED, оптимальный выбор терапии.

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Atrial fibrillation (AF) is a common arrhythmia affecting more than 1–2% of the population increases the risk of stroke 5–7-fold. There is no significant difference in the risk of ischemic stroke among patients with the three types of AF (paroxysmal, persistent, and permanent). Oral anticoagulation clearly prevents ischemic strokes in AF patients. Warfarin, a vitamin K antagonist, was until recently the only available oral anticoagulant for stroke prevention in AF. Warfarin has limitations that have motivated development of several novel oral anticoagulants (NOACs), including apixaban, dabigatran, rivaroxaban, and edoxaban. Clinical trials demonstrate that the NOACs at least as efficacious as warfarin and were associated with lower rates of intracranial bleeding in patients with nonvalvular AF. Choosing antithrombotic treatment involves assessing the benefits of therapy versus its risks. Risk indexes, including CHA₂DS₂-VASc, and HAS-BLED can help determine how to treat patients with AF. Russian and European Guidelines suggest using of NOACs as an alternative to warfarin in patients with nonvalvular AF. Left atrial appendage closure device should be considered only for individuals with a high risk of stroke and a high risk of bleeding while on anticoagulant therapy. Analysis of clinical trial data and recommendations for the management of patients with AF allows to make the decision on the appointment is effective, safe and cost-effective therapy for each patient.

Key words: atrial fibrillation; ischemic stroke; warfarin; novel oral anticoagulants; clinical trials, risk factors, CHA₂DS₂-VASc, HAS-BLED, management.

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Список литературы

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1. Diagnostika i lechenie fibrilliatsii predserdii. Rekomendatsii VNOK, VNOA, ASSKh. 2012. http://scardio.ru/content/Guidelines/FP_rkj_13.pdf [in Russian]
2. Camm AJ, Kirchof P, Lip GYH et al. Guidelines for the management of atrial fibrillation. The task force of the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31: 2369–429.
3. Camm AJ, Lip G, De Caterina R et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. An update of the 2010 ESC Guidelines for the management of atrial fibrillation developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719–247.
4. January CT, Wann LS, Alpert JS et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation 2014; 130 (23): 2071–104.
5. Lloyd-Jones DM, Wang TJ, Leip EP et al. Lifetime risk for development of atrial fibrillations: the Framingham Heart Study. Circulation 2004; 110: 1042–6.
6. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983–8.
7. Hart RG, Pearce LA, Rothbart RM et al. Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy JACC 2000; 35: 183–7.
8. Hart RG, Pearce LA, Koudstaal PJ. Transient Ischemic Attacks in Patients With Atrial Fibrillation: Implications for Secondary Prevention: The European Atrial Fibrillation Trial and Stroke Prevention in Atrial Fibrillation III Trial Stroke 2004; 35: 948–51.
9. Hohnloser SH, Pajitnev D, Pogue J et al. Incidence of Stroke in Paroxysmal Versus Sustained Atrial Fibrillation in Patients Taking Oral Anticoagulation or Combined Antiplatelet Therapy: An ACTIVE W Substudy JACC 2007; 50: 2156–61.
10. Friberg L, Hammar N, Rosenqvist M. Stroke in paroxysmal atrial fibrillation: report from the Stockholm Cohort of Atrial Fibrillation. Eur Heart J 2010; 31: 967–75.
11. Oganov R.G. Sosudistaia komorbidnost': obshchie podkhody k profilaktike i lecheniiu. Rats. farmakoterapiia v kardiologii. 2015; 11 (1): 4–7. [in Russian]
12. Wu N, Tong Sh, Xiang Y. Association of Hemostatic Markers with Atrial Fibrillation: A Meta-Analysis and Meta-Regression. PLoS ONE 2015; 10 (4): e 0124716. doi: 10.1371/journal.pone.0124716
13. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996; 61 (2): 755–9.
14. Aberg H. Atrial fibrillation. I. A study of atrial thrombosis and systemic embolism in a necropsy material. Acta Medica Scandinavica 1969; 185: 373–9.
15. Stoddard MF, Dawkins PR, Prince CR, Ammash NM. Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: A transesophageal echocardiographic study. J Am Coll Cardiol 1995; 25: 452–9.
16. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic Therapy to Prevent Stroke in Patients Who Have Nonvalvular Atrial Fibrillation. Ann Intern Med 2007; 146: 857–67.
17. The ACTIVE Investigators. Effect of Clopidogrel Added to Aspirin in Patients with Atrial Fibrillation. N Engl J Med 2009; 360: 2066–78.
18. Cleland JGF, Cowburn PJ, Falk RH. Should all patients with atrial fibrillation receive warfarin? Evidence from randomized clinical trials. Eur Heart J 1996; 17: 674–81.
19. Hylek EM, Skates SJ. Sheehan MA, Singer D.E. An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N Engl J Med 1996; 335 (8): 540–6.
20. Granger CB, Alexander JH, McMurray JJ et al. For the ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365: 981–92.
21. Connolly SJ, Ezekowitz MD, Yusuf S et al for the RE-LY Steering Committee and Investigators. Dabigatran vs. warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139–51.
22. Patel MR, Mahaffey KW, Garg J et al for the ROCKET-AF Investigators. Rivaroxaban vs. warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365: 883–91.
23. Connolly SJ, Eikelboom J, Joyner C et al for the AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med 2011; 364 (9): 806–17.
24. Giugliano RP, Ruff CT. Braunwald E et al. Edoxaban versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2013; 369: 2093–104.
25. Levi MM, Eerenberg E, Lowenberg E, Kamphuise PW. Bleeding in patients using new anticoagulants or antiplatelet agents: risk factors and management. Neth J Med 2010; 68 (2): 68–76.
26. Hughes M, Lip GY. Stroke and thromboembolism in with atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data. Tromb Haemost 2008; 99: 295–304.
27. Stroke in AF working group. Independent predictors of stroke in patients with atrial fibrillation: a systematic review. Neurology 2007; 69: 546–54.
28. Gage BF, Waterman AD, Shannon W et al. Validation of clinical classification schemes for predicting stroke: results from the National registry of atrial fibrillation. JAMA 2001; 285: 2864–70.
29. Lip GY, Nieuwlaat R, Pisters R et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using anovel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest 2010; 137: 263–72.
30. Pisters R, Lane DA, Nieuwlaat R et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in in patients with atrial fibrillation: the Euro Heart Survey on atrial fibrillation. Chest 2010; 138: 1093–100.
31. Ebright J, Mousa SA. Oral Anticoagulants and Status of Antidotes for the Reversal of Bleeding Risk. Clinical and Applied Nhrombosis/Hemostasis published on-line 12 August 2014. Doi: 10.1177/1076029614545211.
32. Gomes T, Mamdani MM, Holbrook AM et al. Rates of hemorrhage during warfarin therapy for atrial fibrillation. CMAJ 2013; 185: E121–127.
33. Hylek EM, Evans-Molina C, Shea C et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 2007; 115: 2689–96.
34. Camm JA, Colombo A, Corbucci G, Padeletti L. Left atrial appendage closure: a new technique for clinical practice. Heart Rhythm 2014; 11 (3): 514–21.
35. Davtian K.V., Tkacheva O.N., Kalemberg A.A., Koretskii S.N. Pervyi opyt implantatsii okkliuziruiushchikh ustroistv v ushko levogo predserdiia s tsel'iu profilaktiki insul'tov v gosudarstvennom nauchno-issledovatel'skom tsentre profilakticheskoi meditsiny. Rats. farmakoterapiia v kardiologii. 2014; 10 (3): 307–11. [in Russian]
36. Martsevich S.Iu., Voronina V.P., Drozdova L.Iu. Zdorov'e i obrazovanie vracha: dve sostavliaiushchie uspekha. Rats. farmakoterapiia v kardiologii. 2010; 6 (1): 73–6. [in Russian]
37. Dorian P, Kongnakorn Th, Phatak H et al. Cost-effectiveness of apixaban vs. current standard of care for stroke prevention in patients with atrial fibrillation. Eur Heart J 2014; 35: 1897–906.
38. Belousov Iu.B., Iavelov I.S., Belousov D.Iu, Afanas'eva E.V. Priamye zatraty assotsiirovannye s primeneniem varfarina u patsientov s fibrilliatsiei predserdii. Rats. farmakoterapiia v kardiologii. 2011; 5: 561–6. [in Russian]

Авторы

М.Ю.Гиляров1, 2, Е.В.Константинова*1, 3

1 Региональный сосудистый центр ГБУЗ ГКБ №1 им Н.И.Пирогова Департамента здравоохранения г. Москвы. 119049, Россия, Москва, Ленинский пр-т, д. 8;
2 ГБОУ ВПО Первый Московский государственный медицинский университет им. И.М.Сеченова Минздрава России. 119991, Россия, Москва, ул. Трубецкая, д. 8, стр. 1;
3 ГБОУ ВПО Российский национальный исследовательский медицинский университет им. Н.И.Пирогова Минздрава России. 117997, Россия, Москва, ул. Островитянова, д. 1
*katekons@mail.ru

________________________________________________

M.Yu.Gilyarov1, 2, E.V.Konstantinova*1, 3

1 N.I.Pirogov City clinical hospital №1 of the Department of Health of Moscow. 119049, Russian Federation, Moscow, Leninskii pr-t, d. 8;
2 I.M.Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation. 119991, Russian Federation, Moscow, ul. Trubetskaia, d. 8, str. 2
3 N.I.Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation. 117997, Russian Federation, Moscow, ul. Ostrovitianova, d. 1
*katekons@mail.ru

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