BACKGROUND:Non-valvular atrial fibrillation (AF) carries an increased risk of stroke mediated by embolism of stasis-precipitated thrombi originating in the left atrial appendage. Both oral anticoagulants and antiplatelet agents have proven effective for stroke prevention in most patients at high risk for vascular events, but primary stroke prevention in patients with non-valvular AF potentially merits separate consideration because of the suspected cardio-embolic mechanism of most strokes in AF patients. OBJECTIVES:To characterize the relative effect of long-term oral anticoagulant treatment compared with antiplatelet therapy on major vascular events in patients with non-valvular AF and no history of stroke or transient ischemic attack (TIA). SEARCH STRATEGY:We searched the Cochrane Stroke Group Trials Register (June 2006). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to June 2006) and EMBASE (1980 to June 2006). We contacted the Atrial Fibrillation Collaboration and experts working in the field to identify unpublished and ongoing trials. SELECTION CRITERIA:All unconfounded, randomized trials in which long-term (more than four weeks) adjusted-dose oral anticoagulant treatment was compared with antiplatelet therapy in patients with chronic non-valvular AF. DATA COLLECTION AND ANALYSIS:Two review authors independently selected trials for inclusion, assessed quality and extracted data. The Peto method was used for combining odds ratios after assessing for heterogeneity. MAIN RESULTS:Eight randomized trials, including 9598 patients, tested adjusted-dose warfarin versus aspirin (in dosages ranging from 75 to 325 mg/day) in AF patients without prior stroke or TIA. The mean overall follow up was 1.9 years/participant. Oral anticoagulants were associated with lower risk of all stroke (odds ratio (OR) 0.68, 95% confidence interval (CI) 0.54 to 0.85), ischemic stroke (OR 0.53, 95% CI 0.41 to 0.68) and systemic emboli (OR 0.48, 95% CI 0.25 to 0.90). All disabling or fatal strokes (OR 0.71, 95% CI 0.59 to 1.04) and myocardial infarction (OR 0.69, 95% CI 0.47 to 1.01) were substantially but not significantly reduced by oral anticoagulants. Vascular death (OR 0.93, 95% CI 0.75 to 1.15) and all cause mortality (OR 0.99, 95% CI 0.83 to 1.18), were similar with these treatments. Intracranial hemorrhages (OR 1.98, 95% CI 1.20 to 3.28) were increased by oral anticoagulant therapy. AUTHORS' CONCLUSIONS:Adjusted-dose warfarin and related oral anticoagulants reduce stroke, disabling stroke and other major vascular events for those with non-valvular AF by about one third when compared with antiplatelet therapy.

译文

背景:非瓣膜性心房颤动(AF)会增加由左心耳产生的淤积沉淀的血栓栓塞介导的中风风险。事实证明,口服抗凝药和抗血小板药均可在大多数血管事件高风险患者中有效预防卒中,但由于怀疑大多数AF卒中的心脏栓塞机制,对非瓣膜性AF患者的初次卒中预防可能值得单独考虑耐心。
目的:研究长期口服抗凝治疗与抗血小板治疗相比对非瓣膜性房颤,无卒中或短暂性脑缺血发作(TIA)史的患者主要血管事件的相对作用。
搜索策略:我们搜索了Cochrane中风组试验登记册(2006年6月)。我们还搜索了Cochrane对照试验中央注册簿(CENTRAL)(2006年第2期Cochrane图书馆),MEDLINE(1966年至2006年6月)和EMBASE(1980年6月至2006年6月)。我们联系了心房颤动协作组织和该领域的专家,以确定尚未发表和正在进行的试验。
选择标准:所有无混淆的随机试验,将长期(四周以上)调整剂量的口服抗凝治疗与抗血小板治疗相比较,用于慢性非瓣膜性房颤患者。
数据收集与分析:两位评价作者独立选择了纳入,评估质量和提取数据的试验。评估异质性后,使用Peto方法合并比值比。
主要结果:八项随机试验(包括9598名患者)在无中风或TIA的AF患者中测试了调整剂量的华法林与阿司匹林(剂量范围为75至325 mg / day)。平均总体随访时间为1.9年/参与者。口服抗凝剂与降低所有中风的风险(几率(OR)0.68,95%置信区间(CI)0.54至0.85),缺血性中风(OR 0.53,95%CI 0.41至0.68)和全身性栓塞(OR 0.48, 95%CI 0.25至0.90)。口服抗凝剂可以使所有致残或致命性中风(OR 0.71,95%CI 0.59至1.04)和心肌梗塞(OR 0.69,95%CI 0.47至1.01)得到显着但没有显着降低。这些治疗与血管性死亡(OR 0.93,95%CI 0.75至1.15)和所有原因死亡率(OR 0.99,95%CI 0.83至1.18)相似。口服抗凝治疗可增加颅内出血(OR 1.98,95%CI 1.20至3.28)。
作者的结论:与抗血小板治疗相比,调整剂量的华法令和相关的口服抗凝药可使非瓣膜性房颤患者的中风,中风和其他主要血管事件减少约三分之一。

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