心房颤动相关急性脑梗死早期启动抗凝治疗的安全性

doi:10.3969/j.issn.1004-583X.2026.02.003

摘要/Abstract

摘要：

目的探讨在心房颤动相关急性脑梗死患者中,早期启动抗凝治疗相较于常规启动是否能在不增加出血风险的前提下,更有效地降低卒中复发风险并改善功能预后。方法前瞻性收集发病24 h内入院的心房颤动相关急性脑梗死患者80例,随机分为早期组(第3 d启动抗凝)与常规组(第6 d启动抗凝),每组40例。观察90 d内脑梗死复发率、严重出血事件(颅内/消化道出血)、[改良Rankin量表(Modified Rankin Scale, mRS)评分≤2分]、不良事件发生率。结果早期组90 d内卒中复发率显著低于常规组(15.0% vs 50.0%, P<0.01)。90 d功能独立(mRS≤2)患者比例在早期组更高(75.0% vs 50.0%, P<0.05)。两组严重出血事件发生率差异无统计学意义(5.0% vs 7.5%, P>0.05)。亚组分析提示,高卒中风险(CHA₂DS₂-VASc≥4)患者获益尤为显著。结论早期(第3 d)启动抗凝治疗在心房颤动相关急性脑梗死患者中显示出显著的临床获益,包括更低的卒中复发风险和更好的功能恢复,且未显著增加出血风险。

关键词: 卒中, 心房颤动, 早期抗凝治疗, 功能独立性, 复发预防, 安全性评估

Abstract:

Objective To investigate the potential of an early initiation of anticoagulation therapy versus conventional initiation in effectively reducing the risk of stroke recurrence and improving functional prognosis without increasing the bleeding risk in patients with atrial fibrillation-related acute cerebral infarction. Methods A total of 80 patients with atrial fibrillation-related acute cerebral infarction admitted within 24 hours of onset were prospectively allocated. Patients were randomly assigned to the early group (anticoagulation initiated on day 3) and conventional group (initiated on day 6), with 40 cases in each group. The 90-day recurrence rate of cerebral infarction, severe bleeding events (intracranial/gastrointestinal hemorrhage), functional independence (the modified Rankin Scale [mRS]≤2), and adverse event incidence were observed. Results Patients in the early group demonstrated a significantly lower 90-day recurrence rate of cerebral infarction than the conventional group (15.0% vs 50.0%, P<0.01). Additionally, the proportion of patients achieving functional independence (mRS≤2) was significantly higher in the early groupthan the conventional group (75.0% vs 50.0%, P<0.05). No significant difference was observed in the incidence of major bleeding events between the two groups (5.0% vs 7.5%, P>0.05). Subgroup analysis indicated that patients with a high stroke risk (CHA₂DS₂-VASc≥4) benefited more from an early anticoagulation therapy. Conclusion An early initiation of anticoagulation therapy (day 3) in patients with atrial fibrillation-related acute cerebral infarction demonstrated significant clinical benefits, including reduced risk of stroke recurrence and improved functional recovery, without significantly increased the bleeding risk.

Key words: stroke, atrial fibrillation, early anticoagulation therapy, functional independence, prevention of recurrence, safety evaluation

中图分类号:

R743

张艳萍, 李坷, 张壮. 心房颤动相关急性脑梗死早期启动抗凝治疗的安全性[J]. 临床荟萃, 2026, 41(2): 116-121.

Zhang Yanping, Li Ke, Zhang Zhuang. Safety of an early initiation of anticoagulant therapy for atrial fibrillation associated acute cerebral infarction[J]. Clinical Focus, 2026, 41(2): 116-121.

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链接本文: https://www.lchc.cn/CN/10.3969/j.issn.1004-583X.2026.02.003

https://www.lchc.cn/CN/Y2026/V41/I2/116

图/表 5

表1 两组患者一般资料

Tab.1 General information between two groups

组别	例数	性别[例(%)]		发病年龄 (岁)	高血压病史 [例(%)]	糖尿病病史 [例(%)]	心脏病病史 [例(%)]	NIHSS评分 (分)
组别	例数	男性	女性	发病年龄 (岁)	高血压病史 [例(%)]	糖尿病病史 [例(%)]	心脏病病史 [例(%)]	NIHSS评分 (分)
观察组	40	26(65.0)	14(35.0)	73±5	32(80.0)	27(67.5)	19(47.5)	12.3±2.1
对照组	40	22(55.0)	18(45.0)	71±6	36(90.0)	29(72.5)	21(52.5)	12.1±2.4
χ²/t值		0.785		1.156	1.614	0.229	0.184	0.412
P值		0.123		0.250	0.105	0.302	0.668	0.682

表2 两组90 d疗效与安全性终点比较[例 (%)]

Tab.2 90-day efficacy and safety endpoints between the two groups

组别	例数	主要疗效终点 (卒中复发)	次要疗效终点 [功能独立 (mRS≤2)]	安全性终点 (严重出血事件)
早期组	40	6(15.0)	30(75.0)	2(5.0)
常规组	40	20(50.0)	20(50.0)	3(7.5)
χ²值		11.250	5.333
P值		<0.01	0.021	0.500^*

表3 不同亚组中早期与常规抗凝治疗90 d卒中复发率的比较

Tab.3 90-day stroke recurrence rate between early and conventional anticoagulation therapy in different subgroups

亚组	早期组复发/总数(例)	常规组复发/总数(例)	复发率差(%)	P值(亚组内)	交互P值
年龄
≤75岁 >75岁	2/23 4/17	9/22 11/18	-32.2 -37.6	0.009 0.013	0.724
基线NIHSS评分
8~12分 13~15分	2/25 4/15	9/25 11/15	-28.0 -46.7	0.020 0.007	0.452
CHA₂DS₂-VASc评分
<4分 ≥4分	2/17 4/23	3/15 17/25	-8.4 -50.6	0.500 <0.01	0.032
HAS-BLED评分
<3分 ≥3分	1/30 1/10	1/20 2/10	1.7 -10.0	0.673 0.527	0.341

图1 早期与常规抗凝治疗90 d卒中复发率差异的亚组(交互作用)分析森林图注:本图展示早期抗凝相对于常规抗凝在不同预设亚组中对90 d卒中复发率的影响。横坐标为复发率差(%)(早期抗凝-常规抗凝),数值<0表示早期抗凝可降低复发率;红色虚线表示无差异线(0)。右侧为各亚组内比较的P值。图中“交互P”用于检验治疗效应在该分层变量不同水平间是否存在异质性;仅CHA2DS2-VASc分层交互作用检验有统计学意义(交互P=0.032),提示高卒中风险(CHA2DS2-VASc≥4)患者获益更显著,其余分层未见显著交互作用。

Fig.1 Subgroup (interaction) analysis forest map of the absolute difference in 90-day stroke recurrence between early and conventional anticoagulation therapy Note: The forest plot shows the effect of early versus conventional anticoagulation on 90-day stroke recurrence across prespecified subgroups. The x-axis indicates the absolute difference in recurrence rate (%) (early anticoagulation minus conventional anticoagulation); values <0 favor early anticoagulation. The red dashed line denotes no difference (0). P values on the right are within-subgroup comparisons. “P for interaction” tests heterogeneity of treatment effect across levels of each stratification factor; a significant interaction was observed only for CHA2DS2-VASc strata (P for interaction=0.032), suggesting greater benefit in patients with CHA2DS2-VASc ≥4.

表4 两组90 d时改良Rankin量表评分分布比较[例 (%)]

Tab.4 mRS score at 90 days between the two groups(n, %)

mRS评分	早期组(n=40)	常规组(n=40)
0	10(25.0)	4(10.0)
1	10(25.0)	8(20.0)
2	10(25.0)	8(20.0)
3	6(15.0)	12(30.0)
4	2(5.0)	4(10.0)
5	2(5.0)	2(5.0)
6	0(0.0)	2(5.0)

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