請用此 Handle URI 來引用此文件:
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/4655
完整後設資料紀錄
DC 欄位 | 值 | 語言 |
---|---|---|
dc.contributor.advisor | 林慧玲(Fei-Lin Lin Wu) | |
dc.contributor.author | Mu-Mei Hu | en |
dc.contributor.author | 胡慕美 | zh_TW |
dc.date.accessioned | 2021-05-14T17:44:44Z | - |
dc.date.available | 2020-09-24 | |
dc.date.available | 2021-05-14T17:44:44Z | - |
dc.date.copyright | 2015-09-24 | |
dc.date.issued | 2015 | |
dc.date.submitted | 2015-07-27 | |
dc.identifier.citation | 參考文獻 1. Hsieh FI, Lien LM, Chen ST, et al. Get With the Guidelines-Stroke performance indicators: surveillance of stroke care in the Taiwan Stroke Registry: Get With the Guidelines-Stroke in Taiwan. Circulation 2010;122:1116-23. 2. Sanoski CA, Bauman JL. The Arrhythmias. Pharmacotherapy: A Pathophysiologic Approach, 8 th ed New York: McGraw-Hill; 2011:273-94. 3. Lee CH, Liu PY, Tsai LM, et al. Characteristics of hospitalized patients with atrial fibrillation in Taiwan: a nationwide observation. Am J Med 2007;120:819 e1-7. 4. Chien KL, Su TC, Hsu HC, et al. Atrial fibrillation prevalence, incidence and risk of stroke and all-cause death among Chinese. Int J Cardiol 2010;139:173-80. 5. 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. J Am Coll Cardiol 2014;64:e1-e76. 6. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace 2006;8:651-745. 7. Morady F, Zipes DP. Atrial Fibrillation : Clinical Features, Mechanisms, and Management. In: Douglas L. Mann DPZ, Peter Libby, Robert O. Bonow ; founding editor and online editor Eugene Braunwald, ed. Braunwald's heart disease : a textbook of cardiovascular medicine. Tenth edition ed. Philadelphia, PA: Elsevier/Saunders; 2015:798-820. 8. Wang KL, Wu CH, Huang CC, et al. Complexity of atrial fibrillation patients and management in Chinese ethnicity in routine daily practice: insights from the RealiseAF Taiwanese cohort. J Cardiol 2014;64:211-7. 9. Lin LJ, Cheng MH, Lee CH, Wung DC, Cheng CL, Yang YHK. Compliance with antithrombotic prescribing guidelines for patients with atrial fibrillation – a nationwide descriptive study in Taiwan. Clin Ther 2008;30:1726-36. 10. Chao TF, Liu CJ, Wang KL, et al. Using the CHA2DS2-VASc score for refining stroke risk stratification in 'low-risk' Asian patients with atrial fibrillation. J Am Coll Cardiol 2014;64:1658-65. 11. Halperin JL, Hart RG. Atrial fibrillation and stroke: new ideas, persisting dilemmas. Stroke 1988;19:937-41. 12. Yip PK, Jeng JS, Lee TK, et al. Subtypes of ischemic stroke: A hospital-based stroke registry in Taiwan (SCAN-IV). Stroke 1997;28:2507-12. 13. Po HL, Lin YJ. Antithrombotic treatment before stroke onset and stroke severity in patients with atrial fibrillation and first-ever ischemic stroke: An observational study. . Neurology Asia 2010;15:11-7. 14. Lin HJ, Chang WL, Tseng MC. Readmission after stroke in a hospital-based registry: risk, etiologies, and risk factors. Neurology 2011;76:438-43. 15. Yancy CW, Jessup M, Bozkurt B, et al. American College of Cardiology Foundation/American Heart Association Task Force on 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the Practice Guidelines. Circulation 2013;128:e240-e327. 16. Opie LH, Gersh BJ. Drugs For The Heart. Philadelphia, PA: Saunders/Elsevier; 2009. 17. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991;324:781-8. 18. Connolly SJ, Camm AJ, Halperin JL, et al. Dronedarone in high-risk permanent atrial fibrillation. N Engl J Med 2011;365:2268-76. 19. K?ber L, Torp-Pedersen C, McMurray JJ, et al. Increased mortality after dronedarone therapy for severe heart failure. N Engl J Med 2008;358:2678-87. 20. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm 2012;9:632-96 e21. 21. Epstein AE, DiMarco JP, Ellenbogen KA, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2013;61:e6-75. 22. Maisel WH. Left atrial appendage occlusion--closure or just the beginning? N Engl J Med 2009;360:2601-3. 23. Holmes DR, Jr., Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 2014;64:1-12. 24. Whisenant B, Kar S, Bunch TJ. Left atrial appendage occlusion addresses the tremendous unmet needs of stroke prevention in atrial fibrillation that persist despite recent advances in anticoagulation therapy. Circulation 2014;130:1516-23. 25. De Caterina R, Camm AJ. What is 'valvular' atrial fibrillation? A reappraisal. Eur Heart J 2014;35:3328-35. 26. Camm AJ, Lip GY, 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;33:2719-47. 27. Petersen P, Boysen G, Godtfredsen J, Andersen ED, Andersen B. Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK study. Lancet 1989;1:175-9. 28. Connolly SJ, Laupacis A, Gent M, Roberts RS, Cairns JA, Joyner C. Canadian Atrial Fibrillation Anticoagulation (CAFA) Study. J Am Coll Cardiol 1991;18:349-55. 29. Stroke Prevention in Atrial Fibrillation Investigators. Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation 1991;84:527-39. 30. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 1991;323:1505-11. 31. Ezekowitz MD, Bridgers SL, James KE, et al. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators. N Engl J Med 1992:1406-12. 32. EAFT (European Atrial Fibrillation Trial) Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 1993;342:1255-62. 33. Harenberg J, Weuster B, Pfitzer M, et al. Prophylaxis of embolic events in patients with atrial fibrillation using low molecular weight heparin. Semin Thromb Hemost 1993;19 Suppl 1:116-21. 34. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study. Lancet 1994;343:687-91. 35. Stroke Prevention in Atrial Fibrillation Investigators. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. The Lancet 1996;348:633-8. 36. Diener HC, Lowenthal A. Antiplatelet therapy to prevent stroke: risk of brain hemorrhage and efficacy in atrial fibrillation. J Neurol Sci 1997;153:112. 37. Morocutti C, Amabile G, Fattapposta F, et al. Indobufen versus warfarin in the secondary prevention of major vascular events in nonrheumatic atrial fibrillation. SIFA (Studio Italiano Fibrillazione Atriale) Investigators. Stroke 1997;28:1015-21. 38. Gull?v AL, Koefoed BG, Petersen P, et al. Fixed minidose warfarin and aspirin alone and in combination vs adjusted-dose warfarin for stroke prevention in atrial fibrillation: Second Copenhagen Atrial Fibrillation, Aspirin, and Anticoagulation Study. Arch Intern Med 1998;158:1513-21. 39. Pengo V, Zasso A, Barbero F, et al. Effectiveness of fixed minidose warfarin in the prevention of thromboembolism and vascular death in nonrheumatic atrial fibrillation. Am J Cardiol 1998;82:433-7. 40. Hellemons BS, Langenberg M, Lodder J, et al. Primary prevention of arterial thromboembolism in non-rheumatic atrial fibrillation in primary care: randomised controlled trial comparing two intensities of coumarin with aspirin. BMJ 1999;319:958-64. 41. Posada IS, Barriales V. Alternate-day dosing of aspirin in atrial fibrillation. LASAF Pilot Study Group. Am Heart J 1999;138:137-43. 42. Yamaguchi T. Optimal intensity of warfarin therapy for secondary prevention of stroke in patients with nonvalvular atrial fibrillation: a multicenter, prospective, randomized trial. Japanese Nonvalvular Atrial Fibrillation-Embolism Secondary Prevention Cooperative Study Group. Stroke 2000;31:817-21. 43. FFAACS (Fluindione FA, Aspirin et Contraste Spontane´) Investigators,. Anticoagulant (fluindione)-aspirin combination in patients with high-risk atrial fibrillation. A randomized trial (Fluindione, Fibrillation Auriculaire, Aspirin et Contraste Spontane´; FFAACS). Cerebrovasc Dis 2001;12:245-52. 44. Edvardsson N, Juul-Moぴller S, Omblus R, Pehrsson K. Effects of low-dose warfarin and aspirin versus no treatment on stroke in a medium-risk patient population with atrial fibrillation. J Intern Med 2003;254:95-101. 45. Executive Steering Committee on behalf of the SPORTIF III Investigators. Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomised controlled trial. Lancet 2003;362:1691-8. 46. Petersen P, Grind M, Adler J, Investigators. SI. Ximelagatran Versus Warfarin for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation SPORTIF II: A Dose-Guiding, Tolerability, and Safety Study. J Am Coll Cardiol 2003;41:1445-51. 47. Perez-Gomez F, Alegria E, Berjon J, et al. Comparative effects of antiplatelet, anticoagulant, or combined therapy in patients with valvular and nonvalvular atrial fibrillation: a randomized multicenter study. J Am Coll Cardiol 2004;44:1557-66. 48. SPORTIF Executive Steering Committee for the SPORTIF V Investigators. Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial. JAMA 2005;293:690-8. 49. ACTIVE Writing Group on behalf of the ACTIVE Investigators. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 2006;367:1903-12. 50. Antithrombotic Therapy in Atrial Fibrillation Study Group. The randomized study of efficiency and safety of antithrombotic therapy in nonvalvular atrial fibrillation: warfarin compared with aspirin. Zhonghua Xin Xue Guan Bing Za 2006;34:295-8. 51. Sato H, Ishikawa K, Kitabatake A, et al. Low-dose aspirin for prevention of stroke in low-risk patients with atrial fibrillation: Japan Atrial Fibrillation Stroke Trial. Stroke 2006;37:447-51. 52. Vemmos KN, Tsivgoulis G, Spengos K, et al. Primary prevention of arterial thromboembolism in the oldest old with atrial fibrillation--a randomized pilot trial comparing adjusted-dose and fixed low-dose coumadin with aspirin. Eur J Intern Med 2006;17:48-52. 53. Rash A, Downes T, Portner R, Yeo WW, Morgan N, Channer KS. A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO). Age Ageing 2007;36:151-6. 54. The ACTIVE Investigators. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med 2009;360:2066-78. 55. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. The New England Journal of Medicine 2009;361:1139-51. 56. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. The New England Journal of Medicine 2011;365:883-91. 57. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. The New England Journal of Medicine 2011;365:981-92. 58. Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369:2093-104. 59. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57-185. 60. Van de Werf F, Brueckmann M, Connolly SJ, et al. A comparison of dabigatran etexilate with warfarin in patients with mechanical heart valves: THE Randomized, phase II study to evaluate the safety and pharmacokinetics of oral dabigatran etexilate in patients after heart valve replacement (RE-ALIGN). Am Heart J 2012;163:931-7 e1. 61. Eikelboom JW, Connolly SJ, Brueckmann M, et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med 2013;369:1206-14. 62. Chu JW, Chen VH, Bunton R. Thrombosis of a mechanical heart valve despite dabigatran. Ann Intern Med 2012;157:304. 63. Price J, Hynes M, Labinaz M, Ruel M, Boodhwani M. Mechanical valve thrombosis with dabigatran. J Am Coll Cardiol 2012;60:1710-1. 64. Stewart RA, Astell H, Young L, White HD. Thrombosis on a Mechanical Aortic Valve whilst Anti-coagulated With Dabigatran. Heart Lung Circ 2012;21:53-5. 65. Zimetbaum PJ, Thosani A, Yu HT, et al. Are atrial fibrillation patients receiving warfarin in accordance with stroke risk? Am J Med 2010;123:446-53. 66. Palm F, Kleemann T, Dos Santos M, et al. Stroke due to atrial fibrillation in a population-based stroke registry (Ludwigshafen Stroke Study) CHADS(2) , CHA(2) DS(2) -VASc score, underuse of oral anticoagulation, and implications for preventive measures. Eur J Neurol 2013;20:117-23. 67. Liu B, Liu LZ, Xuan J, et al. Treatment patterns associated with stroke prevention in patients with atrial fibrillation in three major cities in the People's Republic of china. Int J Gen Med 2013;7:29-35. 68. 鄭明惠. 心房顫動病患使用抗血栓劑之處方型態分析[碩士論文]. 國立成功大學 2007. 69. 王敏如. 心房顫動病患使用抗血栓劑符合準則與否和心血管事件發生關聯性探討[碩士論文]. 國立成功大學 2008. 70. Yu HC, Tsai YF, Chen MC, Yeh CH. Underuse of antithrombotic therapy caused high incidence of ischemic stroke in patients with atrial fibrillation. Int J Stroke 2012;7:112-7. 71. Larsen TB, Rasmussen LH, Skjoth F, et al. Efficacy and safety of dabigatran etexilate and warfarin in 'real-world' patients with atrial fibrillation: a prospective nationwide cohort study. J Am Coll Cardiol 2013;61:2264-73. 72. Olesen JB, Sorensen R, Hansen ML, et al. Non-vitamin K antagonist oral anticoagulation agents in anticoagulant naive atrial fibrillation patients: Danish nationwide descriptive data 2011-2013. Europace 2015;17:187-93. 73. Cunningham A, Stein CM, Chung CP, Daugherty JR, Smalley WE, Ray WA. An automated database case definition for serious bleeding related to oral anticoagulant use. Pharmacoepidemiol Drug Saf 2011;20:560-6. 74. Hickey K. Anticoagulation management in clinical practice: preventing stroke in patients with atrial fibrillation. Heart lung : the journal of critical care 2012;41:146-56. 75. 黃天祈、林宗憲、溫文才、賴文德、許勝雄. 目前心房顫動患者合併抗血小板藥物和抗凝血劑治療的醫學證據. 內科學誌 2014;25:381-8. 76. Gupta M, Ha AC, Cox JL, et al. Factors Associated with New Oral Anticoagulant Versus Vitamin K Antagonist Use in a Contemporary, National, Real-World Observational Registry: Insights from the Stroke Prevention and Rhythm Interventions in Atrial Fibrillation (Sprint-Af) Registry. J Am Coll Cardiol 2014;63:A331. 77. Lauffenburger JC, Farley JF, Gehi AK, Rhoney DH, Brookhart MA, Fang G. Factors driving anticoagulant selection in patients with atrial fibrillation in the United States. Am J Cardiol 2015;115:1095-101. 78. Elewa HF, DeRemer CE, Keller K, Gujral J, Joshua TV. Patients satisfaction with warfarin and willingness to switch to dabigatran: a patient survey. J Thromb Thrombolysis 2014;38:115-20. 79. 黃淑萍. 某醫學中心心房纖維顫動病患特性與其抗血栓劑處方型態之研究[碩士論文]. 國立臺灣大學 2005. 80. Chiang CE, Zhang S, Tse HF, Teo WS, Omar R, Sriratanasathavorn C. Atrial fibrillation management in Asia: from the Asian expert forum on atrial fibrillation. Int J Cardiol 2013;164:21-32. 81. Bjerring Olesen J, Gislason GH, Torp-Pedersen C, Lip GY. Atrial fibrillation and vascular disease—a bad combination. Clin Cardiol 2012;35:S15-S20. 82. Violi F, Lip GY, Basili S. Peripheral artery disease and atrial fibrillation: a potentially dangerous combination. Intern Emerg Med 2012;7:213-8. 83. Rosanio S, Keylani AM, D'Agostino DC, DeLaughter CM, Vitarelli A. Pharmacology, benefits, unaddressed questions, and pragmatic issues of the newer oral anticoagulants for stroke prophylaxis in non-valvular atrial fibrillation and proposal of a management algorithm. Int J Cardiol 2014;174:471-83. 84. Lin LY, Lee CH, Yu CC, et al. Risk factors and incidence of ischemic stroke in Taiwanese with nonvalvular atrial fibrillation - a nation wide database analysis. Atherosclerosis 2011;217:292-5. 85. Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. The Lancet 2013;381:1107-15. | |
dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/4655 | - |
dc.description.abstract | 背景: 心房顫動 (atrial fibrillation; AF) 為臨床上常見之心律不整,且為中風的危險因子。過去治療準則建議使用抗血栓劑 (包含抗血小板劑以及抗凝血劑) 預防中風,其中抗凝血劑僅有warfarin可使用。過去文獻指出實際上使用抗血栓劑的比例偏低,warfarin的使用比例低於三成。目前新一代口服抗凝血劑 (Non-vitamin K antagonist oral anticoagulation; NOAC) 包括dabigatran、rivaroxaban、apixaban已在臺灣上市,國際治療準則也建議這些藥品為warfarin之外的替代選項。 目的: 目前臺灣仍缺乏NOAC的相關研究,藥品上市後的臨床使用情況仍然所知有限。本研究的目的為分析NOAC在臺灣的使用現況及其預測因子。 研究方法: 本研究屬於回溯性觀察研究,分析民國96年1月1日至102年12月31日臺大醫院門診、住院、急診出現至少三次AF診斷 (ICD-9 CM code 427.31) 的非瓣膜性AF病人。研究主要分成兩個部分: (一) 觀察目前NOAC和warfarin的使用情況 (二) 開方因子分析:找出是否使用抗凝血劑、抗凝血劑使用種類、從warfarin換藥至NOAC的可能影響因素。使用多變項羅吉斯複迴歸模式分析可能影響開方的因子。 結果: 最終納入3662位病人,平均年齡為69歲,主要分布在大於等於75歲的年齡層 (38.6%),女性病人較少 (45.5%)。平均CHADS2 score為1.4分、CHA2DS2-VASc score 2.8分、HAS-BLED score為2.0分。高血壓是病人最常見的共病,比例為52.1%,其次為缺血性心臟病 (27.4%)、糖尿病 (20.8%)、血脂異常 (19.2%)。在1215位使用抗凝血劑的病人中有23.6% 使用NOAC,76.4%使用warfarin。在研究期間,warfarin的使用情況呈現減少趨勢,而NOAC則呈現增加趨勢。依據目前治療準則的建議,我們發現本研究CHA2DS2-VASc score兩分以上的病人,32.48%使用抗凝血劑,以warfarin使用者為主 (71.3%)、dabigatran次之 (26.03%),rivaroxaban最少 (2.67%),未使用抗凝血劑的比例有67.52%。於CHA2DS2-VASc score一分以上的病人,也有類似的結果。 開方因子分析部分,中風或栓塞史、降血壓藥品、糖尿病藥品、減少出血風險藥品的使用會增加抗凝血劑使用機會,女性、高血壓、缺血性心臟病、癌症、肝疾病、腎疾病、出血史、aspirin使用則降低抗凝血劑的開方機會。年齡增加、缺血性心臟病、糖尿病、肥厚性心肌病變、周邊血管疾病、癌症、失智症、aspirin使用會增加NOAC開方機會,肝疾病、腎疾病、中風或栓塞史則降低NOAC開方機會。年齡增加會增加warfarin換藥至NOAC的機會,腎疾病、出血史則降低換藥機會。 結論: 本研究提供目前臺灣NOAC在臺大醫院的使用現況。我們發現AF病人使用NOAC的比例正在增加,而warfarin的比例正在下降。和現行治療準則對照,在建議使用抗凝血劑的族群實際用藥的比例約在32.5%。中風及栓塞史會增加抗凝血劑開方機會,然而易增加出血風險的共病則減少抗凝血劑開方。健保給付規範在本研究可能影響抗凝血劑使用的種類。年齡增加的warfarin使用者有較大機會換藥至NOAC,腎疾病及有出血史病人較不會換藥。 | zh_TW |
dc.description.abstract | Background : Atrial fibrillation (AF) is one of the risk factors for ischemic stroke. In the past, warfarin had been the drug of choice for pharmacological stroke prevention in AF, especially for those at higher risk of stroke. Previous literatures showed low prescription rate for warfarin in AF patients. Non-vitamin K antagonist oral anticoagulation (NOAC) agents have been approved by FDA for stroke prevention as alternatives to warfarin in non-valvular AF patients and have been available in Taiwan since 2012. So far, there is limited real-world data on how NOAC agents are currently being used and whether current treatment guidelines are followed among health care professionals in Taiwan. Objectives : We aim to provide answers to the following topics : (1) Patterns of anticoagulants utilization in Taiwanese AF patients (2) Factors driving the initiation of anticoagulant treatment (no anticoagulant treatment vs. anticoagulant use) and the selection of and switching between different anticoagulants (warfarin or NOAC). Methods : We used National Taiwan University Hospital (a 2500-bed tertiary medical center) electronic database to include all non-valvular AF patients from 1 January 2007 to 31 December 2013. Multivariate logistic regression models were used to examine factors driving the initiation of anticoagulant treatment and the selection of and switching between different anticoagulants. Results : Of 3662 patients identified in our study, the average age was 69 years, 38.6% of patients were aged ≥ 75 years and 45.5% were female. Among study population, hypertension was the most common comorbidities (52.1%) and 27.4% had ischemic heart disease, 20.8% had diabetes and 19.2% had dyslipidemia. Of 1215 anticoagulant users, 23.6% and 76.4% were on NOAC and warfarin, respectively. Nearly 32.5% patients with CHA2DS2-VASc score ≥ 2 were on anticoagulant according to current treatment guideline. Among these users, 71.3% and 28.9% were on warfarin and NOACs, respectively. Similar trends were found in patients with CHA2DS2-VASc score ≥ 1. Patients with female gender, hypertension, ischemic heart disease, cancer, hepatic disease, renal disease, bleeding history, aspirin use were less likely to be anticoagulant user while more likely with stroke history (OR 2.64, 95% CI 2.02 to 3.45). Older age, ischemic heart disease, diabetes, peripheral vascular disease were some of the factors associated with NOAC use while hepatic and renal disease showed the opposite results (OR for hepatic disease 0.34, 95% CI 0.12 to 0.99; OR for renal disease 0.27, 95% CI 0.10 to 0.73). Among 928 warfarin users, 18.9% switched to NOAC during study period. Warfarin users with older age were more likely to switch to NOAC and less likely with renal disease and bleeding history (OR for renal disease 0.16, 95% CI 0.04 to 0.69; OR for bleeding history 0.33, 95% CI 0.12 to 0.93). Conclusion : Our study provides current patterns of anticoagulant utilization in National Taiwan University Hospital. Among patients initiated anticoagulant treatment, 23.6% used NOAC instead of warfarin. During study period, the prescription rate for NOAC was rending up and in warfarin user we found the opposite trend. Nearly 32.5% patients received anticoagulant prescription according to current treatment guideline. Stroke history was associated with anticoagulant use while comorbidities associated increased bleeding risk showed opposite result. NHI Prescribing recommendations for NOAC may affect the selection for anticoagulants. Warfarin users with older age were more likely to switch to NOAC, whereas renal disease and bleeding history were less likely associated with switching. | en |
dc.description.provenance | Made available in DSpace on 2021-05-14T17:44:44Z (GMT). No. of bitstreams: 1 ntu-104-R02451007-1.pdf: 9180585 bytes, checksum: adf17c4baee773a8b03d3dd587a2c287 (MD5) Previous issue date: 2015 | en |
dc.description.tableofcontents | 目錄
口試委員會審定書……………………………………………………………………. I 致謝…………………………………………………………………...………………. II 中文摘要………………………………………………………………..……………. III 英文摘要…………………………………………………………..………………….. V 目錄…………………………………………………………………………………. VII 圖目錄……………………………………………………………………………….. XI 表目錄………………………………………………………………………………. XII 第一章 前言……………………………………………………………...…......…… 1 第二章 疾病簡介………………………………………...………………………..… 2 2.1 流行病學..............…….………………………..………………………….... 2 2.2 診斷及分類 ………….……………..………………...………….………… 2 2.3 病理機轉…. ………….…………………..……………………………….... 3 2.4 危險因子…. ………….………………………………...……….………...... 3 2.5 併發症……. ………….……………………………...……………………... 4 第三章 心房顫動之治療………………………………………...………………….... 5 3.1控制心跳………………..……………………..…………….……………..... 5 3.1.1 藥品治療………………………….……...…..………………….…….. 5 3.1.1.1乙型受體阻斷劑………………………………………………...... 5 3.1.1.2鈣離子通道阻斷劑……………………………………………….. 6 3.1.1.3毛地黃……………………………………………………...……... 6 3.1.2 非藥品治療……………………………..…………..………………..... 7 3.2回復正常心律……………………………………….…..………………...… 7 3.2.1 藥品治療………………………………….…………..…………..…… 7 3.2.1.1藥品綜述………………………………………………….............. 7 3.2.1.2 Amiodarone和dronedarone比較…………………………………. 8 3.2.2 非藥品治療……………………….……………………..……..……..... 9 3.2.2.1直流電擊復律術………………………………………………….... 9 3.2.2.2經導管燒灼術…………………………………………………….... 9 3.2.2.3心臟節律器……………………………………………………...... 10 3.2.2.4迷宮手術…………………………………………………….…..... 10 3.2.2.5處置前後之栓塞預防…………………………………………...... 10 3.3栓塞預防………………………………….……………………………….... 11 3.3.1 非藥品治療………………………………………….……………… 11 3.3.2 藥品治療…………………………………….…………………….… 12 第四章 文獻探討:抗血栓劑在心房顫動的角色………………………………….. 14 4.1 臨床試驗…………………………………………………………….……... 14 4.2 國際治療準則……………………………………………….……………... 17 4.3 不同抗血栓劑之比較……………………………….……………………... 18 4.4 抗血栓劑於心房顫動之臨床使用……………………………………….... 19 4.4.1 臨床開方情形……………………………………………………….... 19 4.4.2 影響處方行為之可能因素……………………………………….…... 20 第五章 研究目的……………………………………………………………….…… 22 5.1 研究動機………………………………………………………………...… 22 5.2 研究重要性……………………………………………………………...… 22 第六章 研究方法……………………………………………………………………. 23 6.1 研究設計…………………………………………………………………... 23 6.2 資料蒐集…………………………………………………………………... 23 6.2.1 資料來源……………………………………………………………... 23 6.2.2 研究對象……………………………………………………………... 24 6.2.2.1 納入條件………………………………………………………... 24 6.2.2.2 排除條件………………………………………………………... 24 6.2.2.3 基本資料………………………………………………………... 24 6.2.2.4 共病史…………………………………………………………... 25 6.2.2.5 用藥情況………………………………………………………... 26 6.2.2.6 生化檢驗數值……..……………………….……………….…... 26 6.2.2.7 CHA2DS2-VASc score計算…………………………………... 26 6.2.2.8 HAS-BLED score計算……..…………….………………….... 26 6.3 資料分析……………………………………………………………….….. 27 6.3.1 抗凝血劑使用現況……………………………...…………………… 27 6.3.1.1整體心房顫動病人特性……………………………………….... 27 6.3.1.2抗凝血劑之開方趨勢………………………………………….... 27 6.3.1.3抗血小板劑開方及後續新開方抗凝血劑比例……………….... 27 6.3.1.4不同抗凝血劑使用情形之病人特性………………………….... 28 6.3.1.5抗凝血劑使用與現行治療準則之對照…………………….…... 28 6.3.1.6開方醫師科別分析…………….…………………………....…... 28 6.3.2 不同抗凝血劑使用情形之預測因子…...………………………..….. 28 6.4 統計方法……………………………………..………………………….... 29 6.5 研究流程圖……………………………………………………………..… 29 第七章 結果………………………………………………………………...……….. 30 7.1抗凝血劑使用現況……………………………...…………….......………. 30 7.1.1整體心房顫動病人特性……………………………………………... 30 7.1.2抗凝血劑之開方趨勢………………………………………………... 31 7.1.3抗血小板劑開方及後續新開方抗凝血劑比例……………………... 31 7.1.4不同抗凝血劑使用情形之病人特性………………………………... 32 7.1.5抗凝血劑使用與現行治療準則之對照……………………………... 34 7.1.6開方醫師科別分析…………….……………….…………………..... 34 7.2不同抗凝血劑使用情形之預測因子…...……………………………….... 35 7.2.1是否使用抗凝血劑…………………………………………………... 35 7.2.2抗凝血劑使用種類………………………………………………..... 35 7.2.3不同抗凝血劑轉換…………………………………………..……... 35 第八章 討論……………………………………………………………………..… 36 8.1抗凝血劑使用現況……………………………...…………….......……... 36 8.1.1整體心房顫動病人特性…………………………………………..... 36 8.1.2抗凝血劑之開方趨勢…………………………………………..…... 36 8.1.3抗血小板劑開方及後續新開方抗凝血劑比例…………………..... 37 8.1.4不同抗凝血劑使用情形之病人特性…………………………..…... 38 8.1.5抗凝血劑使用與現行治療準則之對照…………………………..... 40 8.1.6開方醫師科別分析…………….……………….…………………... 40 8.2不同抗凝血劑使用情形之預測因子…...……………………………….. 41 8.2.1是否使用抗凝血劑……………………………………………..…... 41 8.2.2抗凝血劑使用種類……………………………………………..…... 42 8.2.3不同抗凝血劑轉換………………………………………………..... 43 8.3研究限制….......................…...…………………………………….…….. 44 第九章 結論與未來方向………………………………………………………….. 46 參考文獻…………………………………………………………………..……… 115 | |
dc.language.iso | zh-TW | |
dc.title | 臺灣心房顫動患者抗凝血劑使用現況及預測因子 | zh_TW |
dc.title | Predictors and Patterns of Warfarin and Non-vitamin K Antagonist Oral Anticoagulation (NOAC) Use in Patients with Atrial Fibrillation in Taiwan | en |
dc.type | Thesis | |
dc.date.schoolyear | 103-2 | |
dc.description.degree | 碩士 | |
dc.contributor.coadvisor | 林珍芳(Zhen-Fang Lin) | |
dc.contributor.oralexamcommittee | 沈麗娟(Li-Jiuan Shen),劉言彬(Yen-Bin Liu) | |
dc.subject.keyword | 心房顫動,新一代口服抗凝血劑,中風, | zh_TW |
dc.subject.keyword | atrial fibrillation,Non-Vitamin K antagonist oral anticoagulation,NOAC, | en |
dc.relation.page | 122 | |
dc.rights.note | 同意授權(全球公開) | |
dc.date.accepted | 2015-07-27 | |
dc.contributor.author-college | 藥學專業學院 | zh_TW |
dc.contributor.author-dept | 臨床藥學研究所 | zh_TW |
顯示於系所單位: | 臨床藥學研究所 |
文件中的檔案:
檔案 | 大小 | 格式 | |
---|---|---|---|
ntu-104-1.pdf | 8.97 MB | Adobe PDF | 檢視/開啟 |
系統中的文件,除了特別指名其著作權條款之外,均受到著作權保護,並且保留所有的權利。