Atriyal fibrilasyon (AF) gözlenen hastaların demografik, biyokimyasal ve hematolojik parametrelerinin değerlendirilmesi
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Tarih
2015
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Erişim Hakkı
info:eu-repo/semantics/closedAccess
Özet
Giriş ve amaç Atriyal fibrilasyon klinik uygulamalarda en sık karşılaşılan aritmi türüdür. Atriyal fibrilasyonun en önemli mortal ve morbid komplikasyonlarından birisi iskemik inmedir. Bu komplikasyonun bazı çalışmalarda tüm AF tiplerinde meydana gelme riskinin benzer olduğu belirtilmiştir. Antikoagülasyon tüm AF tiplerinde tromboembolik komplikasyonları önlemede kabul edilmiş bir tedavi modalitesidir. Çalışmamızda hastanemiz kardiyoloji polikliniğine başvuran veya kardiyoloji klniğinde yatarak takip edilen AF hastalarını 2010 Atriyal Fibrilasyon Tedavi Kılavuzu önerilerine göre; Atriyal Fibrilasyon tipine göre sınıflandırmış, AF tipine göre sınıflandırılmış olan hasta gruplarının Ejeksiyon Fraksiyonu, Sol Atriyum çapı, hematolojik ve biokimyasal parametreleri, kullandıkları ilaçları, eşlik eden hastalıkları karşilaştırılmış, hastalar iskemik inme gelişim riski CHADS2 ve CHA2DS2-VASc Skoruna göre, hastaların kanama riski HASBLED skoruna göre karşılaştırılmıştır. Materyal-metod Çalışmamızda Ocak 2012- Ekim 2013 tarihleri arasında Dicle Üniversitesi Tıp Fakültesi Hastanesi Kardiyoloji polikliniğine başvuran ve/veya kliniğinde yatan AF tanılı 200 hasta retrospektif olarak incelendi. Çalışmada Valvüler AF’ li olgular dışlanma kriteri olarak kabul edildi. Hasta dosya kayıtları ve hastane sistemi üzerinden hastaların adı, soyadı, protokol numarası, telefon numarası, adres bilgileri, yaş, cinsiyet bilgileri, boy, kilo, AF türleri, eşlik eden hastalıklar (DM, HT, KAH, KY, İKMP, DKMP, HKMP, Tirotoksikoz, İskemik/Hemorajik İnme, GİA, Sistemik Emboli) , kullandıkları ilaçlar, OAK ve/veya antiagregan tedavi kullanımları, OAK tedavi almama nedenleri, başvuruda ortalama INR değerleri, rutin biyokimyasal ve hematolojik parametreler ile ekokardiyografi bilgilerine ulaşıldı. Hastalar telefon numaralarından aranarak eksik bilgilerine ulaşıldı. Hastaların iskemik inme riskinin hesaplanması için CHA2DS2-VASc, CHADS2 skorları belirlendi. Hastaların kanama riskinin belirlenmesi için HASBLED skoru hesaplandı. Daha sonra hastaların tüm verileri Paroksismal AF (PAF) ve Persistant-Permanent AF (PPAF) grupları arasında istatistiksel olarak karşılaştırıldı. Bulgular Çalışmaya alınan 200 hastanın 144’ ü (% 72) persistent/permanent AF (PPAF), 56’ sı (% 28) paroksismal AF (PAF)’ idi. Hastaların 116’ sı(%58) kadın, 84’ ü (%42) erkekti. PAF’ lı olgularla PPAF’ li olgular arasında cinsiyet açısından anlamlı farklılık bulunamadı (p>0,05). Tüm hastaların yaşları ortalaması 68,72±11,67 yıl. PAF’ lı olguların ortalama yaşı 63,94±12,39 yıl PPAF’ li olguların ortalama yaşı 70,57±10,86 yıl her iki grup arasında anlamlı fark mevcuttu(p<0,001). Hastaların ortalama CHA2DS2-VASc skoru 3,52±1,72 PAF’ lı olguların ortalama CHA2DS2-VASc skoru 2,67±1,68 PPAF’ li olguların ortalama CHA2DS2-VASc skoru 3,85±1,63 olup her iki grup arasında anlamlı farklılık mevcuttu(p<0,001). PAF’ lı hastalar ile PPAF’ li olguların CHA2DS2 -VASc gruplarına göre Düşük-Orta risk gruplarının karşılaştırılmasında stroke riski açısından anlamlı fark izlenmedi(p:0,577). Düşük-Yüksek risk gruplarının karşılaştırılmasında stroke riski açısından anlamlı fark izlendi(p<0,001). Orta-Yüksek risk gruplarının karşılaştırılmasında stroke riski açısından anlamlı fark izlendi(p<0,001). İnme/TİA, KKY, Yaş>75 yıl, İskemik KMP oranları anlamlı olarak PPAF’ li grupta daha yüksek düzeyde izlendi (p<0,05). Hastaların ortalama HASBLED skoru 1,95±1,17 PAF’ lı olguların ortalama HASBLED skoru 1,32±1,02 PPAF’ li olguların ortalama HASBLED skoru 2,20±1,14 olup her iki grup arasında anlamlı fark mevcuttu(p<0,001). PPAF’ li grupta oral antikoagülan (warfarin) tedavi alma oranı ve efektif INR düzeyine ulaşma sıklığı anlamlı olarak daha yüksekti(p<0,05). PPAF’ li grupta ACEİ/ARB, diüretik, digoxin, klopidogrel kullanma oranları anlamlı olarak daha yüksekti(p<0,05). Ekokardiyografik değerlendirmede PPAF’ li grupta EF anlamlı olarak daha düşük ve sol atriyum çapı anlamlı olarak daha büyüktü(p<0,05). PPAF’ li olgularda tam kan parametrelerinden NLR, platelet, RDW değerleri anlamlı olarak daha yüksekti (p<0,05). PPAF’ li olgularda üre, ALT, ürik asit, indirekt bilirubin, trigliserid, total kolesterol, LDL, HDL, glukoz, GGT, CRP, INR değerleri anlamlı olarak daha yüksek saptandı(p<0,05). Tüm Hastalarımızda oral antikoagülan tedavi almamanın en sık nedeni %61,7 ile "hekim tarafından başlanmama" olarak saptandı. Çalışmamızda PPAF’ nin bağımsız prediktifleri HASBLED skoru, LA çapı, GGT bulundu. Tartışma AF hastalarının büyük çoğunluğu iskemik inme yönünden yüksek riske sahiptir. Çalışmamızda PAF’ lı olguların kılavuzların belirttiği CHA2DS2-VASc skoruna göre benzer inme riskine sahip olduğu ancak PPAF’ li olguların ise kılavuzların belirttiği CHA2DS2-VASc skoruna göre belirtilen inme riskinden daha yüksek riski sahip olduğu görüldü. Çalışmamızda PPAF’ li olguların eşlik eden komorbiditeler açısından PAF’ lı olgulara göre klinik durumu daha ağır hastalar olduğu görüldü. Hematolojik ve biokimyasal değerlendirmelerde PPAF’ li olguların daha iyi olmayan sonuçlara sahip olduğu izlendi. Oral antikoagülan tedavinin inmeyi önlemedeki faydalarını gösteren önemli çalışmalara rağmen; yüksek inme riskine sahip AF hastalarının sadece dörtte birinin (%27) oral antikoagülan tedavi aldığı bunların da ancak yarısına yakını (%45) efektif INR değerine sahip olduğu görüldü. Günlük klinik pratiğini yansıtan bu çalışmada yetersiz oral antikoagülan tedavi alımının tıbbi kontrendikasyonlardan ziyade önemli bir nedeni olarak hekimlerin yetersiz reçetelemesi bulunmuştur. Sonuç Literatürde her ne kadar tüm AF türlerinde iskemik inme riskinin arttığı bildirilmekte ise de, bizim çalışmamızda PPAF’ lı hastaların PAF’ lı hastalara göre daha fazla komorbid hastalığa sahip olduğu ve daha yüksek oranda iskemik inme ve kanama riski taşıdıklarını desteklemektedir.
Introduction Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. Ischemic stroke (IS) is the most disabling and even mortal complication of AF. A number of study reports that risk of IS is similar in all AF types. Anticoagulation is the accepted method of prevention of thromboembolic complications in all types of nonvalvular AF. In our study, all patients with AF admitted to cardiology outpatient clinic or hospitalized were categorized according to recommendations in 2010 Guideline for the management AF of European Society of Cardiology (ESC); and patients in each nonvalvular AF types were compared in terms of ejection fraction (EF), left atrial (LA) diameter, hematologic and biochemical parameters, medication, concomitant diseases, and future IS risk of AF patients was assessed with CHADS2 and CHADS2VA2Sc scores, and bleeding risk was assessed with HASBLED scores. Material and Methods A total of 200 consecutive patients with nonvalvular AF admitted to outpatient cardiology clinic or hospitalized at Dicle University Faculty of Medicine between Jan’12-Oct’13 were evaluated retrospectively. Valvular AF patients were not included in the present study. Patient infomations including name, age, gender, address, phone number, height, weight, AF type, concomitant diseases (diabetes mellitus [DM], hypertension [HT], heart failure [HF], ischemic cardiomyopathy [ICMP], dilated cardiomyopathy [DCMP], tyrotoxicosis, ischemic/hemorrhagic stroke, transient ischemic attack [TIA], systemic emboli), medication, were obtained from digital patient files. Also oral anticoagulant (OAC) and antiaggregant drug usage, reason why do not use OAC despite high (>2) CHA2DS2VASc score, INR value on admission, haematological and biochemical test results, and echocardiographic measures were recorded and analyzed for all patients with each AF type. Future IS risk of patients with nonvalvular AF were assessed with CHA2DS2VASc scores, while bleeding risk was assessed with HASBLED score. All of these variables were compared between paroxysmal AF (PAF) and persistent-permanent AF (PPAF) patient groups. Results The study population consist of 200 patients, 116 women (58%), was categorized as 144 patients with PPAF (72%) and 56 patients with PAF (28%). Both groups were similar in terms of gender. Mean age of the study population was 68.7 ± 11.7 years, while patients in PAF group were younger (63.9 ± 12.4) than PPAF group (70.6 ± 10.9 years) (p < 0.001). Mean CHADS2VA2Sc score of the study population was 3.52 ± 1.72; while that was higher in the PPAF group (3.85 ± 1.63) than that of PAF group (2.67±1.68) (p < 0.001). However when the patients were classified into low-medium-high risk profile for future stroke, the groups were similar with respect to low-or-medium class (p = 0.577), but there was a significant difference between groups when compared according to low-or-high risk class (p < 0.001), and medium-or-high class (p < 0.001). Patients with stroke/TIA, congestive HF, age > 75 years, and ICMP were significantly more frequent in the PPAF group (p < 0.05 for each). Mean HASBLED score of the study population was 1.95 ± 1.17, while PPAF group had significantly higher mean HASBLED score than PAF group (2.20±1.14 vs. 1.32±1.02 respectively; p < 0.001). OAC (warfarin) usage and achievement and maintenance of effective INR values were more frequent in the PPAF group than PAF group (p < 0.05 for each). The most frequent reason for not to use OAC (warfarin) in the whole study population was “not advised by the physician” with a ratio of 62 %. Meanwhile, the patients in the PPAF group were receiving medication with ACE inhibitor/ARB, diuretic, digoxin and clopidogrel more frequently than that of patients in the PAF group (p < 0.05 for each). On the echocardiographic examination, the PPAF group had lower EF and larger LA diameter than the PAF group (p < 0.05 for each). With respect to hematologic parameters, the patients in the PPAF group had higher neutrophil-to-lymphocyte ratio (NLR), platelet count, and red cell distribution width (RDW) than the PAF group (p < 0.05 for each). PPAF group had higher urea, ALT, uric acid, indirect bilirubin, triglyceride, total cholesterol, LDL, HDL, fasting glucose, GGT, and CRP level than the PAF group (p < 0.05 for each). By the multivariate logistic regression analysis, the HASBLED score, LA diameter, and GGT level were found to be the independent predictors of PPAF. Discussion Patient with AF are exposed to high risk of ischemic stroke. Our study suggest that patients with PAF are exposed to a similar IS risk as mentioned in the guideline (2010 ESC Guideline on the management of AF) while patient with PPAF have had a greater IS risk than predicted in the guideline according to their CHA2DS2VASc score. Also patients with PPAF have had more frequent concomitant debilitating disorders than PAF patients. Hematologic and biochemical parameters were poorer in the PPAF group. Despite numerous studies reporting high effectiveness of OAC treatment in the prevention IS in AF patients; only 27% of the high-risk patients in our study population were under OAC treatment and only 45% of them had been in the effective therapeutic INR ranges. OAC prescription habits of physicians to the high risk AF patients in the daily practice was assessed in the present study and inadequate advisement of OAC by physicians was found to be the most common reason of “not to use OAC”, in spite of medical contraindications. Conclusion As a conclusion, although it is reported in the literature that all types of AF patients carry an increased risk for future ischemic stroke, our study suggest that patients with PPAF have co-morbid disorders more commonly and they are exposed to higher risk for ischemic stroke and bleeding compared to patients with PAF.
Introduction Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. Ischemic stroke (IS) is the most disabling and even mortal complication of AF. A number of study reports that risk of IS is similar in all AF types. Anticoagulation is the accepted method of prevention of thromboembolic complications in all types of nonvalvular AF. In our study, all patients with AF admitted to cardiology outpatient clinic or hospitalized were categorized according to recommendations in 2010 Guideline for the management AF of European Society of Cardiology (ESC); and patients in each nonvalvular AF types were compared in terms of ejection fraction (EF), left atrial (LA) diameter, hematologic and biochemical parameters, medication, concomitant diseases, and future IS risk of AF patients was assessed with CHADS2 and CHADS2VA2Sc scores, and bleeding risk was assessed with HASBLED scores. Material and Methods A total of 200 consecutive patients with nonvalvular AF admitted to outpatient cardiology clinic or hospitalized at Dicle University Faculty of Medicine between Jan’12-Oct’13 were evaluated retrospectively. Valvular AF patients were not included in the present study. Patient infomations including name, age, gender, address, phone number, height, weight, AF type, concomitant diseases (diabetes mellitus [DM], hypertension [HT], heart failure [HF], ischemic cardiomyopathy [ICMP], dilated cardiomyopathy [DCMP], tyrotoxicosis, ischemic/hemorrhagic stroke, transient ischemic attack [TIA], systemic emboli), medication, were obtained from digital patient files. Also oral anticoagulant (OAC) and antiaggregant drug usage, reason why do not use OAC despite high (>2) CHA2DS2VASc score, INR value on admission, haematological and biochemical test results, and echocardiographic measures were recorded and analyzed for all patients with each AF type. Future IS risk of patients with nonvalvular AF were assessed with CHA2DS2VASc scores, while bleeding risk was assessed with HASBLED score. All of these variables were compared between paroxysmal AF (PAF) and persistent-permanent AF (PPAF) patient groups. Results The study population consist of 200 patients, 116 women (58%), was categorized as 144 patients with PPAF (72%) and 56 patients with PAF (28%). Both groups were similar in terms of gender. Mean age of the study population was 68.7 ± 11.7 years, while patients in PAF group were younger (63.9 ± 12.4) than PPAF group (70.6 ± 10.9 years) (p < 0.001). Mean CHADS2VA2Sc score of the study population was 3.52 ± 1.72; while that was higher in the PPAF group (3.85 ± 1.63) than that of PAF group (2.67±1.68) (p < 0.001). However when the patients were classified into low-medium-high risk profile for future stroke, the groups were similar with respect to low-or-medium class (p = 0.577), but there was a significant difference between groups when compared according to low-or-high risk class (p < 0.001), and medium-or-high class (p < 0.001). Patients with stroke/TIA, congestive HF, age > 75 years, and ICMP were significantly more frequent in the PPAF group (p < 0.05 for each). Mean HASBLED score of the study population was 1.95 ± 1.17, while PPAF group had significantly higher mean HASBLED score than PAF group (2.20±1.14 vs. 1.32±1.02 respectively; p < 0.001). OAC (warfarin) usage and achievement and maintenance of effective INR values were more frequent in the PPAF group than PAF group (p < 0.05 for each). The most frequent reason for not to use OAC (warfarin) in the whole study population was “not advised by the physician” with a ratio of 62 %. Meanwhile, the patients in the PPAF group were receiving medication with ACE inhibitor/ARB, diuretic, digoxin and clopidogrel more frequently than that of patients in the PAF group (p < 0.05 for each). On the echocardiographic examination, the PPAF group had lower EF and larger LA diameter than the PAF group (p < 0.05 for each). With respect to hematologic parameters, the patients in the PPAF group had higher neutrophil-to-lymphocyte ratio (NLR), platelet count, and red cell distribution width (RDW) than the PAF group (p < 0.05 for each). PPAF group had higher urea, ALT, uric acid, indirect bilirubin, triglyceride, total cholesterol, LDL, HDL, fasting glucose, GGT, and CRP level than the PAF group (p < 0.05 for each). By the multivariate logistic regression analysis, the HASBLED score, LA diameter, and GGT level were found to be the independent predictors of PPAF. Discussion Patient with AF are exposed to high risk of ischemic stroke. Our study suggest that patients with PAF are exposed to a similar IS risk as mentioned in the guideline (2010 ESC Guideline on the management of AF) while patient with PPAF have had a greater IS risk than predicted in the guideline according to their CHA2DS2VASc score. Also patients with PPAF have had more frequent concomitant debilitating disorders than PAF patients. Hematologic and biochemical parameters were poorer in the PPAF group. Despite numerous studies reporting high effectiveness of OAC treatment in the prevention IS in AF patients; only 27% of the high-risk patients in our study population were under OAC treatment and only 45% of them had been in the effective therapeutic INR ranges. OAC prescription habits of physicians to the high risk AF patients in the daily practice was assessed in the present study and inadequate advisement of OAC by physicians was found to be the most common reason of “not to use OAC”, in spite of medical contraindications. Conclusion As a conclusion, although it is reported in the literature that all types of AF patients carry an increased risk for future ischemic stroke, our study suggest that patients with PPAF have co-morbid disorders more commonly and they are exposed to higher risk for ischemic stroke and bleeding compared to patients with PAF.
Açıklama
Anahtar Kelimeler
Atriyal fibrilasyon (AF), Atrial fibrillation, Demografi, Demography, Hematoloji, Hematology, Kalp, Heart, Kalp hastalıkları, Heart diseases
