JAMA：心房颤动老年病人中女性的中风风险高于男性

5月9日，国际杂志《美国医学会杂志》JAMA上的一项研究披露，在一项检查老年患者被诊断患有心房颤动之后使用抗凝药华法林及中风风险的研究中，女性，特别是那些75岁以上者，其罹患中风的风险要高于男性，而这与其风险概况及华法林的使用无关，从而提示目前的用抗凝疗法来防止中风的做法对老年女性而言可能是不够的。

根据文章的背景资料：“心房颤动（AF）是最常见的心率失常，它占了因为心率紊乱而住院病例中的近三分之一。”有人提出女性口服抗凝药物的使用不足是这一风险增加的一个促成因素。

蒙特利尔市麦吉尔大学健康中心的Meytal Avgil Tsadok， Ph.D.及其同事们对罹患心房颤动（AF）的年龄在65岁或以上的男女中的华法林的使用模式及随后的中风发病率进行了比较。应用在出院、医生与处方药索赔数据库间联动的管理数据，这一研究包括了从1998-2007年间在加拿大魁北克省住院的那些入院前不久被诊断患有AF的病人。

该组群由3，9398名男性（47.2%）和4，4115名女性（52.8%）组成。在入院的时候，女性的年龄较大（74.2%的女性年龄大于75岁，而男性的这一百分比为61.4%）并有着比男性更高的CHADS2（充血性心衰、高血压、年龄75岁或以上、糖尿病、先前有中风或短暂性缺血发作）评分。华法林处方率在女性中要比在男性中略高（女性中为60.6% vs.男性中为58.2%）；与男性相比，女性往往会在出院后30天内更多地按处方获取华法林。在出院后1年内进行评估时，华法林处方药的获取比例在女性中会小幅地增加至68%，该比例在男性中也会有所增加。在一般情况下，抗凝疗法的遵守度相对较高且在两性中的情况相似。

研究人员发现，女性中风的粗略发病率比男性显著要高（5.8% vs. 4.3%）。两性间的这一差异主要是因为受到老年患者（75岁及以上者）发病率的驱动。文章的作者写道：“此外，老年女性比老年男性的中风率显著要高，这与华法林的使用无关，而女性的中风率比男性更高，这与服药遵守度水平无关。”在对各种因素进行校正之后，分析表明，女性的中风风险比男性要高14%。

“尽管流行病学研究对中风发生的性别差异进行了调查，但人们对现实世界的临床环境中男女两性间的华法林有效性差别却所知甚少。我们的结果提示，可能需要针对罹患心房颤动（AF）的老年女性进行更有效的中风预防治疗。临床医生应该了解心房颤动（AF）老年女性中提升了的中风风险，而人们应该用新的策略来同样有效地防止在男性和女性中的中风。”

doi:10.1001/jama.2012.3490
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Sex Differences in Stroke Risk Among Older Patients With Recently Diagnosed Atrial Fibrillation

Meytal Avgil Tsadok, PhD; Cynthia A. Jackevicius, PharmD, MSc; Elham Rahme, PhD; Karin H. Humphries, DSc; Hassan Behlouli, PhD; Louise Pilote, MD, MPH, PhD

Context Stroke is a serious complication associated with atrial fibrillation (AF). Women with AF are at higher risk of stroke compared with men. Reasons for this higher stroke risk in women remain unclear, although some studies suggest that undertreatment with warfarin may be a cause. Objective To compare utilization patterns of warfarin and the risk of subsequent stroke between older men and women with AF at the population level. Design, Setting, and Patients Population-based cohort study of patients 65 years or older admitted to the hospital with recently diagnosed AF in the province of Quebec, Canada, 1998-2007, using administrative data with linkage between hospital discharge, physicians, and prescription drug claims databases. Main Outcome Measures Risk of stroke. Results The cohort comprised 39 398 men (47.2%) and 44 115 women (52.8%). At admission, women were older and had a higher CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack) score than men (1.99 [SD, 1.10] vs 1.74 [SD, 1.13], P < .001). At 30 days postdischarge, 58.2% of men and 60.6% of women had filled a warfarin prescription. In adjusted analysis, women appeared to fill more warfarin prescriptions compared with men (odds ratio, 1.07 [95% CI, 1.04-1.11]; P < .001). Adherence to warfarin treatment was good in both sexes. Crude stroke incidence was 2.02 per 100 person-years (95% CI, 1.95-2.10) in women vs 1.61 per 100 person-years (95% CI, 1.54-1.69) in men (P < .001). The sex difference was mainly driven by the population of patients 75 years or older. In multivariable Cox regression analysis, women had a higher risk of stroke than men (adjusted hazard ratio, 1.14 [95% CI, 1.07-1.22]; P < .001), even after adjusting for baseline comorbid conditions, individual components of the CHADS2 score, and warfarin treatment. Conclusion Among older patients admitted with recently diagnosed AF, the risk of stroke was greater in women than in men, regardless of warfarin use.