心房顫動(dòng)相關(guān)缺血性卒中的研究進(jìn)展

李姝雅，王伊龍，王擁軍

心房顫動(dòng)（atrial fibrillation，AF）是最常見的室上性心動(dòng)過(guò)速，人群總體患病率為0.4%～1.0%[1-2]。一些心房顫動(dòng)患者缺乏明顯的、特征性的臨床表現(xiàn)，許多患者直到出現(xiàn)嚴(yán)重并發(fā)癥時(shí)才被檢出心房顫動(dòng)。心房顫動(dòng)是缺血性卒中的一個(gè)重要的獨(dú)立危險(xiǎn)因素，約每6例卒中患者中有1例是心房顫動(dòng)患者[3]。伴心房顫動(dòng)的缺血性卒中患者復(fù)發(fā)率高、預(yù)后差，給社會(huì)和家庭造成沉重的負(fù)擔(dān)[4-9]。合理應(yīng)用抗凝治療可降低心房顫動(dòng)患者的卒中風(fēng)險(xiǎn)[10-11]，過(guò)度抗凝治療增加患者出血風(fēng)險(xiǎn)[12-13]。由于目前醫(yī)療水平的限制及循證醫(yī)學(xué)資料的匱乏，對(duì)于心房顫動(dòng)患者的檢出和管理仍缺乏有效的、一致的意見，探索卒中合并心房顫動(dòng)患者管理規(guī)范尤為重要。

1 心房顫動(dòng)患者的卒中危險(xiǎn)分層評(píng)估和新型抗凝藥物的發(fā)展

抗凝治療可以降低心房顫動(dòng)患者卒中發(fā)生率，但因出血風(fēng)險(xiǎn)而限制其臨床應(yīng)用。鑒于抗凝的利弊，評(píng)估心房顫動(dòng)患者卒中發(fā)生風(fēng)險(xiǎn)和出血風(fēng)險(xiǎn)，平衡利弊，顯得極為重要。20世紀(jì)90年代初，學(xué)者們就致力于建立一個(gè)有效的心房顫動(dòng)患者卒中危險(xiǎn)評(píng)分工具（表1）[14-21]，經(jīng)過(guò)20年的不斷發(fā)展，最新的卒中危險(xiǎn)分層工具是CHADS2評(píng)分（Congestiveheart failure，Hypertension，Age＞75 yrs，Diabetes mellitus，prior Stroke and TIA）[22]和CHA2DS2_VASc評(píng)分［Congestive heart failure，Hypertension，Age≥75（Doubled），Diabetes，Stroke（doubled），Vascular disease，Age 65～74，and Sex category（female）］[23]（表2）。CHADS2評(píng)分和CHA2DS2_VASc評(píng)分已在歐洲、日本、韓國(guó)等多個(gè)地區(qū)心房顫動(dòng)人群中進(jìn)行驗(yàn)證，得到其預(yù)測(cè)1年心源性卒中風(fēng)險(xiǎn)的曲線下面積（area under curve，AUC）（C值）在0.60～0.63[24-26]。2001年問(wèn)世的CHADS2評(píng)分是基于專家共識(shí)產(chǎn)生的總分為6分的經(jīng)典危險(xiǎn)分層工具，在其產(chǎn)生隊(duì)列中顯示出良好的效度（C=0.82）。該評(píng)分因操作簡(jiǎn)單，效度良好，一經(jīng)問(wèn)世即在臨床上廣泛應(yīng)用，隨著臨床試驗(yàn)的不斷檢驗(yàn)，Lip等[27]根據(jù)臨床實(shí)踐修訂了CHADS2的危險(xiǎn)分層標(biāo)準(zhǔn)。Gage等[28]將更改了分層方法的CHADS2評(píng)分在“心房顫動(dòng)患者應(yīng)用口服凝血酶抑制劑預(yù)防卒中研究”（Stroke Prevention using an ORal Thrombin Inhibitor in atrial Fibrillation，SPORTIF）中進(jìn)行驗(yàn)證，約60%的患者被分為中?；颊?，指南中對(duì)于中?；颊呖顾ㄋ幬镞x擇沒(méi)有明確推薦，限制了CHADS2評(píng)分對(duì)抗栓藥物應(yīng)用的指導(dǎo)意義。2010年CHA2DS2_VASc評(píng)分是一種以危險(xiǎn)因素為基礎(chǔ)評(píng)價(jià)非瓣膜性心房顫動(dòng)患者的方法，改進(jìn)了心房顫動(dòng)患者發(fā)生卒中的危險(xiǎn)分層。這一評(píng)分方法將CHADS2評(píng)分得到的中危人群比例降低到原來(lái)的1/4，進(jìn)一步增強(qiáng)了評(píng)分工具對(duì)抗凝治療的指導(dǎo)意義[23]。根據(jù)上述評(píng)分標(biāo)準(zhǔn)，對(duì)于伴心房顫動(dòng)的缺血性卒中患者，屬于存在既往卒中病史的心房顫動(dòng)患者，至少得到2分，屬高危分層，需抗凝治療。

表1 心房顫動(dòng)患者卒中風(fēng)險(xiǎn)評(píng)分工具

表2 CHADS2和CHA2DS2_VASc評(píng)分

卒中等血栓栓塞性并發(fā)癥是心房顫動(dòng)患者致死、致殘的主要原因，合理的抗凝治療對(duì)于改善心房顫動(dòng)患者生活質(zhì)量和遠(yuǎn)期預(yù)后具有重要意義。雖然國(guó)內(nèi)外相關(guān)指南均建議給予高危心房顫動(dòng)患者血栓預(yù)防治療，但迄今多數(shù)患者并未得到相應(yīng)處理，這與口服抗凝藥物的選擇限制密切相關(guān)[29-30]。目前成熟的口服抗凝藥物只有維生素K拮抗劑華法林。華法林應(yīng)用時(shí)需根據(jù)凝血酶原國(guó)際標(biāo)準(zhǔn)化比值（international normalized ratio，INR）調(diào)整劑量，且其抗凝效果受食物影響大，出院患者自行用藥風(fēng)險(xiǎn)極大。新型口服抗凝劑凝血因子Ⅹa抑制劑克服了上述困難，具備高效、安全、固定劑量、無(wú)需監(jiān)測(cè)INR的特點(diǎn)，未來(lái)將占據(jù)口服抗凝藥物的市場(chǎng)，為抗凝治療帶來(lái)新的時(shí)代。達(dá)比加群酯（Pradaxa）、利伐沙班（rivaroxaban）和阿哌沙班（apixaban）是目前批準(zhǔn)上市的新型抗凝藥物。這三類新型抗凝藥物都經(jīng)過(guò)了大型臨床試驗(yàn)的證實(shí)，在抗凝療效和出血風(fēng)險(xiǎn)方面不同程度地優(yōu)于阿司匹林和華法林，這就意味著在心房顫動(dòng)相關(guān)卒中預(yù)防中新型抗凝劑時(shí)代已經(jīng)到來(lái)[22，31-35]。

2 伴心房顫動(dòng)的缺血性卒中患者抗凝治療的出血風(fēng)險(xiǎn)

伴心房顫動(dòng)的缺血性卒中患者的抗凝治療是一把雙刃劍，在對(duì)心房顫動(dòng)患者進(jìn)行抗凝治療的同時(shí)應(yīng)當(dāng)評(píng)估其出血風(fēng)險(xiǎn)（表3）。出血風(fēng)險(xiǎn)的研究略晚于心房顫動(dòng)患者的卒中風(fēng)險(xiǎn)，最早的出血風(fēng)險(xiǎn)評(píng)分工具誕生于1998年[36]，以年齡、2周內(nèi)胃腸道出血、卒中史及并發(fā)癥為危險(xiǎn)因素，根據(jù)得分判斷出血風(fēng)險(xiǎn)，其用C值代表的預(yù)測(cè)大出血的效度為0.78。1年后，Kuijer等[37]提出了以年齡、性別和癌癥三種危險(xiǎn)因素組成的抗凝治療出血風(fēng)險(xiǎn)預(yù)測(cè)評(píng)分，在其驗(yàn)證隊(duì)列中，用C值代表的評(píng)分對(duì)大出血的預(yù)測(cè)效度為0.82［95%可信區(qū)間（confidence interval，CI）：0.66～0.98］。因出血風(fēng)險(xiǎn)與年齡呈正相關(guān)，Shireman等[38]提出了一個(gè)適用于年齡＞65歲心房顫動(dòng)患者的評(píng)分工具，其低、中、高?；颊叩某鲅史謩e為0.9%、2.0%和5.4%。2006年，Gage等[39]發(fā)表了出血危險(xiǎn)的預(yù)測(cè)量表模型：肝臟或腎臟疾病、酗酒、惡性腫瘤、高齡、血小板計(jì)數(shù)或功能降低、再次出血、高血壓、貧血、基因因素、容易摔倒危險(xiǎn)和卒中（Hepatic or renal disease，Ethanol abuse，Malignancy，Older age，Reduced platelet count or function，Re-bleeding，Hypertension，Anemia，Genetic factors，Excessive fall risk and Stroke；HEMORR2HAGES）評(píng)分工具，該評(píng)分方法較為繁瑣，但心房顫動(dòng)患者抗凝治療的出血風(fēng)險(xiǎn)隨著得分的增加而增高。2010年P(guān)isters等[40]提出的另一個(gè)預(yù)測(cè)模型：高血壓、肝/腎功能異常、卒中、出血史或易于出血因素、不穩(wěn)定國(guó)際標(biāo)準(zhǔn)化比值、老年人、藥物/酒精（Hypertension，Abnormal renal/liver function，Stroke，Bleeding history or predisposition，Labile international normalized ratio，Elderly，Drugs/alcohol，HAS-BLED）評(píng)分量表因操作簡(jiǎn)單，對(duì)單純抗血小板治療及非抗栓治療組出血風(fēng)險(xiǎn)的預(yù)測(cè)能力則強(qiáng)于其他評(píng)分系統(tǒng)（C值分別為0.91和0.80），成為歐洲心臟病協(xié)會(huì)（European Society of Cardiology，ESC）心房顫動(dòng)管理指南對(duì)出血風(fēng)險(xiǎn)定量分析的推薦工具（表4）。該量表總分為9分，規(guī)定HAS-BLED評(píng)分≥3分為高危人群，1～2分為中危人群，0分為低危人群，對(duì)于高危人群，在應(yīng)用抗凝藥物或阿司匹林時(shí)需密切注意全身出血傾向。

表3 心房顫動(dòng)患者抗凝治療出血風(fēng)險(xiǎn)評(píng)分

表4 HAS-BLED評(píng)分

HAS-BLED評(píng)分指導(dǎo)抗凝治療需與心房顫動(dòng)患者卒中風(fēng)險(xiǎn)評(píng)分工具合用。在心房顫動(dòng)患者中同時(shí)應(yīng)用CHADS2和HAS-BLED評(píng)分將會(huì)減少12%接受抗凝治療而出血的人數(shù)。當(dāng)CHADS2評(píng)分≥2時(shí)，患者存在卒中高風(fēng)險(xiǎn)，推薦抗凝治療，若此時(shí)HAS-BLED評(píng)分大于CHADS2評(píng)分，則出血風(fēng)險(xiǎn)超過(guò)抗凝獲益。對(duì)于CHADS2評(píng)分=1分的患者，HAS-BLED評(píng)分與CHADS2評(píng)分相差不超過(guò)2分時(shí)，抗凝獲益大于出血風(fēng)險(xiǎn)[41]。

上述5種抗凝治療出血風(fēng)險(xiǎn)預(yù)測(cè)工具均是在未接受抗凝治療的研究隊(duì)列中產(chǎn)生和驗(yàn)證，為進(jìn)一步預(yù)測(cè)接受抗凝治療的患者自發(fā)性腦出血風(fēng)險(xiǎn)，F(xiàn)ang等[42]提出了基于心房顫動(dòng)抗凝和危險(xiǎn)因素的研究（Anticoagulation and Risk Factors in Atrial Fibrillation，ATRIA）評(píng)分。該研究在基于社區(qū)的大規(guī)模心房顫動(dòng)患者隊(duì)列中建立了評(píng)估華法林相關(guān)出血風(fēng)險(xiǎn)評(píng)估的有效方法，在最終風(fēng)險(xiǎn)模型中識(shí)別出5個(gè)獨(dú)立變量，包括貧血、腎臟疾?。I小球?yàn)V過(guò)率＜30 ml/min或接受透析）、年齡≥75歲、曾因出血住院和高血壓。效度分析得到的C統(tǒng)計(jì)值為0.74。評(píng)分劃分低危（0～3分）、中危（4分）和高危（5～10分）患者的主要出血事件發(fā)生率分別為0.8%、2.6%和5.8%。ATRIA評(píng)分產(chǎn)生后，Lip等[43]將HEMORR2HAGES評(píng)分，HAS-BLED評(píng)分和ATRIA評(píng)分的預(yù)測(cè)能力進(jìn)行了比較。效度分析（relative operating characteristic，ROC分析）顯示HAS-BLED評(píng)分預(yù)測(cè)任何臨床相關(guān)出血方面最佳，但三者對(duì)出血風(fēng)險(xiǎn)均有較保守的預(yù)測(cè)能力（C值均＜0.7）。在改善分析（net reclassification index，NRI）中，HASBLED評(píng)分被證實(shí)相對(duì)于HEMORR2HAGES及ATRIA評(píng)分可以分別改善10.3%和13%。使用決定曲線分析（detrended correspondence analysis，DCA）顯示，HAS-BLED評(píng)分在臨床相關(guān)出血事件任何界值水平方面優(yōu)于ATRIA和HEMORR2HAGES評(píng)分。另外，顱內(nèi)出血是抗凝治療中最危險(xiǎn)的并發(fā)癥，只有HAS-BLED評(píng)分對(duì)顱內(nèi)出血具有預(yù)測(cè)價(jià)值。因此，HAS-BLED評(píng)分可能成為指南推薦工具。Lip教授[44]評(píng)論：“HAS-BLED高評(píng)分不能被認(rèn)為是停止抗凝治療的指標(biāo)，而是促使臨床醫(yī)師關(guān)注這類需要特別留意與隨訪的高?；颊?。HAS-BLED評(píng)分使臨床醫(yī)師考慮潛在的可糾正的出血風(fēng)險(xiǎn)因素，比如未控制的血壓，不穩(wěn)定的INR值，以及合并用藥中的阿司匹林及非甾體抗炎藥。”來(lái)自中國(guó)臺(tái)灣[45]和西班牙[46]的數(shù)據(jù)同樣證實(shí)了HAS-BLED評(píng)分的優(yōu)勢(shì)。目前，HAS-BLED評(píng)分是唯一國(guó)際指南推薦的抗凝治療風(fēng)險(xiǎn)預(yù)測(cè)評(píng)分[47－49]。

3 提高卒中患者伴發(fā)心房顫動(dòng)的檢出率

陣發(fā)性和無(wú)癥狀性心房顫動(dòng)難以檢出，因此隱源性卒中和短暫性腦缺血發(fā)作患者可能存在未診斷的心房顫動(dòng)，心房顫動(dòng)的檢出在卒中二級(jí)預(yù)防中處于關(guān)鍵優(yōu)先地位。我國(guó)心源性卒中的整體出院診斷率為6%～7%，這與國(guó)外報(bào)道的20%比例相距甚遠(yuǎn)[22，49]，從一個(gè)側(cè)面說(shuō)明了我國(guó)心源性卒中的診斷率較低。研究證實(shí)通過(guò)新技術(shù)延長(zhǎng)心電監(jiān)測(cè)時(shí)間可提高心房顫動(dòng)檢出率，但其成本效益存在爭(zhēng)議[50-54]。美國(guó)的一項(xiàng)研究對(duì)卒中患者心房顫動(dòng)檢出（Score for the Targeting of Atrial Fibrillation，STAF）評(píng)分≥5分的患者進(jìn)行連續(xù)21 d心電監(jiān)測(cè)，心源性卒中的診斷率提高到13%，這比當(dāng)時(shí)的總體診斷率提高了6%[51]。另一研究提出，通過(guò)延長(zhǎng)心電監(jiān)測(cè)時(shí)間每多診斷一位心源性卒中患者需要耗費(fèi)的成本為44 000美元[52]。對(duì)患者進(jìn)行心房顫動(dòng)風(fēng)險(xiǎn)評(píng)估，針對(duì)高?；颊哐娱L(zhǎng)心電監(jiān)測(cè)時(shí)間，提高心房顫動(dòng)檢出率，是符合成本效益的卒中二級(jí)預(yù)防內(nèi)容。2010年Suissa等[55]提出了STAF評(píng)分系統(tǒng)，從4個(gè)方面對(duì)卒中患者進(jìn)行評(píng)分，總分為8分（表5）。根據(jù)相應(yīng)的受試者工作特征（receiver operating characteristic，ROC）曲線得出總得分＜5分，心源性卒中的可能性＜10%；如果總分≥5分，心源性卒中的可能性則可以達(dá)到90%，建議進(jìn)一步延長(zhǎng)心電監(jiān)測(cè)時(shí)間。該評(píng)分識(shí)別心房顫動(dòng)患者的敏感性為89%，特異性為88%。陣發(fā)性心房顫動(dòng)和短陣心房顫動(dòng)是提高心房顫動(dòng)檢出率的關(guān)鍵。Suissa等[56]提出，STAF評(píng)分≥5分對(duì)于陣發(fā)性心房顫動(dòng)和持續(xù)性心房顫動(dòng)的作用無(wú)顯著性差異，兩者的C值分別為0.907和0.911，其識(shí)別陣發(fā)性心房顫動(dòng)的敏感性為91%，特異性為77%。德國(guó)的一項(xiàng)研究進(jìn)一步探討了STAF評(píng)分對(duì)于陣發(fā)性心房顫動(dòng)的預(yù)測(cè)能力[57]。效度分析結(jié)果提示C值為0.84，STAF評(píng)分≥5分對(duì)于識(shí)別陣發(fā)性心房顫動(dòng)的敏感性為79%，特異性為74%。繼STAF評(píng)分之后，Malik等[58]提出了用于卒中患者心房顫動(dòng)風(fēng)險(xiǎn)預(yù)測(cè)的LADS評(píng)分（Left atrial diameter，Age，Diagnosis of stroke or TIA，and Smoking status）（表5）。該評(píng)分總分為6分，規(guī)定≥4分為心房顫動(dòng)高風(fēng)險(xiǎn)患者，其識(shí)別心房顫動(dòng)患者的敏感性為85.5%，特異性為53.1%。經(jīng)過(guò)LADS評(píng)分的分類，可減少47%的卒中或TIA患者接受長(zhǎng)時(shí)間心電監(jiān)測(cè)。由于LADS評(píng)分的預(yù)測(cè)能力略低于STAF評(píng)分，目前尚無(wú)對(duì)LADS評(píng)分進(jìn)一步驗(yàn)證的相關(guān)研究。

STAF評(píng)分篩選出卒中患者中伴發(fā)心房顫動(dòng)的高危人群，高危人群需延長(zhǎng)心電監(jiān)測(cè)時(shí)間進(jìn)一步檢出心房顫動(dòng)，目前相關(guān)指南尚未對(duì)心電監(jiān)測(cè)時(shí)長(zhǎng)給予建議，研究建議對(duì)卒中患者早期實(shí)施心房顫動(dòng)篩查有助于提高心房顫動(dòng)的檢出率，最短監(jiān)測(cè)時(shí)間為4 d[59]。可插入心臟監(jiān)測(cè)器這一新技術(shù)不僅較7 d的連續(xù)心電監(jiān)測(cè)提高心房顫動(dòng)的檢出率，且對(duì)患者而言更易耐受，無(wú)不良反應(yīng)，將成為提高心房顫動(dòng)檢出率的新方向[55，60]。

表5 STAF和LADS評(píng)分

4 伴心房顫動(dòng)的缺血性卒中患者的不良預(yù)后量表

目前，尚無(wú)單純用于伴心房顫動(dòng)的缺血性卒中患者的不良預(yù)后量表。用于心房顫動(dòng)患者卒中危險(xiǎn)分層的CHADS2和CHA2DS2_VASc評(píng)分，其組成元素均為卒中復(fù)發(fā)和卒中后死亡的獨(dú)立危險(xiǎn)因素。由此推測(cè)，兩種評(píng)分工具可能對(duì)于發(fā)生缺血性卒中的心房顫動(dòng)患者卒中復(fù)發(fā)和不良預(yù)后方面有一定的預(yù)測(cè)價(jià)值。既往研究將CHADS2和CHA2DS2_VASc評(píng)分應(yīng)用于伴非瓣膜性心房顫動(dòng)的缺血性卒中患者預(yù)后結(jié)局的預(yù)測(cè)，發(fā)現(xiàn)這兩種評(píng)分工具是不良預(yù)后和死亡的獨(dú)立危險(xiǎn)因素[61-63]。希臘的一項(xiàng)研究將CHA2DS2_VASc評(píng)分應(yīng)用于非心房顫動(dòng)患者，中、高危分層患者的5年死亡率，卒中復(fù)發(fā)率和聯(lián)合心血管事件明顯高于低危分層的患者[64]。

心房顫動(dòng)或不伴心房顫動(dòng)患者的不良預(yù)后危險(xiǎn)因素基本一致是CHA2DS2_VASc評(píng)分可用于不伴心房顫動(dòng)患者預(yù)后評(píng)價(jià)的基礎(chǔ)。隨著大型高質(zhì)量隊(duì)列研究的逐漸發(fā)展和完善，研究者們提出了多個(gè)不良預(yù)后風(fēng)險(xiǎn)預(yù)測(cè)模型（表6）。這些風(fēng)險(xiǎn)預(yù)測(cè)模型未將伴心房顫動(dòng)的缺血性卒中排除在外，可初步作為心房顫動(dòng)相關(guān)卒中的預(yù)后評(píng)估工具。

表6 缺血性卒中死亡和不良預(yù)后評(píng)估量表

iScore評(píng)分[65]是基于加拿大卒中登記的一項(xiàng)較早的預(yù)測(cè)模型，預(yù)測(cè)急性缺血性卒中患者30 d和1年的死亡風(fēng)險(xiǎn)。預(yù)測(cè)模型在建模隊(duì)列（30 d死亡，C=0.85；1年死亡，C=0.823）、內(nèi)部驗(yàn)證隊(duì)列（30 d死亡，C=0.851；1年死亡，C=0.84）和外部驗(yàn)證隊(duì)列（30 d死亡，C=0.79；1年死亡，C=0.782）中均得到較好的預(yù)測(cè)效度。隨后，iScore評(píng)分分別用于不良預(yù)后風(fēng)險(xiǎn)預(yù)測(cè)，溶栓患者出血風(fēng)險(xiǎn)及預(yù)后轉(zhuǎn)歸預(yù)測(cè)，均得到理想結(jié)果[66-68]。PLAN評(píng)分[69]預(yù)測(cè)模型來(lái)源于另一個(gè)加拿大卒中登記，用于預(yù)測(cè)缺血性卒中患者出院30 d、1年的死亡率和出院時(shí)改良Rankin量表（modified Rankin Scale，mRS）評(píng)分5～6分。預(yù)測(cè)模型包括9項(xiàng)臨床指標(biāo)，操作相對(duì)簡(jiǎn)單，可以準(zhǔn)確預(yù)測(cè)急性缺血性卒中患者30 d死亡（C=0.87），出院時(shí)死亡或嚴(yán)重致殘（C=0.88）、1年死亡（C=0.84）。同時(shí)也可以預(yù)測(cè)出院時(shí)的良好結(jié)局（mRS 0～2）（C=0.80）。美國(guó)心臟協(xié)會(huì)在其協(xié)作醫(yī)院的冠狀動(dòng)脈疾病單元中推行的跟著指南走（Get-with-the-Guideline）建立了在院死亡模型[70]，其包括美國(guó)國(guó)立衛(wèi)生研究院卒中量表（National Institutes of Health Stroke Scale，NIHSS）評(píng)分的預(yù)測(cè)模型對(duì)于院死亡的預(yù)測(cè)效度為0.85（0.84～0.86）。

洛桑卒中登記（The Acute STroke Registry and Analysis of Lausanne，ASTRAL）評(píng)分預(yù)測(cè)模型[71]主要預(yù)測(cè)不良預(yù)后風(fēng)險(xiǎn)，不良預(yù)后定義為mRS評(píng)分＞2分。在建模隊(duì)列中預(yù)測(cè)3個(gè)月不良預(yù)后風(fēng)險(xiǎn)的C值為0.86，在兩個(gè)其他隊(duì)列研究中進(jìn)行外部驗(yàn)證，C值分別為0.937和0.771，預(yù)測(cè)效度良好。博洛尼亞研究（the Bologna Outcome Algorithm for Stroke，BOAS）模型[72]是意大利博洛尼亞市登記隊(duì)列推出的用于預(yù)測(cè)9個(gè)月不良預(yù)后的模型，包括NIHSS評(píng)分、年齡、上肢永久癱瘓、吸氧和導(dǎo)尿5個(gè)危險(xiǎn)因素，每個(gè)危險(xiǎn)因素1分，總分為5分。0～1分為低危分組，2～5分為高危分組。該評(píng)分在建模隊(duì)列（C=0.891，95%CI 0.848～0.934）和驗(yàn)證隊(duì)列（C=0.845，95%CI 0.770～0.920）中均表現(xiàn)出良好的預(yù)測(cè)能力。美國(guó)弗明漢心臟登記研究建立了用于心臟病一級(jí)預(yù)防的（Framingham Cardiovascular Risk Score，F(xiàn)CRS）模型[73]，將FCRS模型用于卒中二級(jí)預(yù)防出院時(shí)不良預(yù)后風(fēng)險(xiǎn)預(yù)測(cè)和出院去向預(yù)測(cè)，得到FCRS模型對(duì)于出院時(shí)mRS≥2分的比值比（odds ratio，OR）為4.9（95%CI 0.98～24.1），出院回家的OR=0.18（95%CI 0.04～0.86），F(xiàn)CRS模型是對(duì)缺血性卒中患者出院回家的保護(hù)性因素。

上述預(yù)測(cè)模型適用于缺血性卒中患者，缺血性卒中患者發(fā)病機(jī)制及病理生理特點(diǎn)異質(zhì)性較強(qiáng)，建立針對(duì)伴心房顫動(dòng)的缺血卒中患者的預(yù)測(cè)模型仍有待進(jìn)一步研究。

5 伴心房顫動(dòng)的缺血性卒中研究展望

美國(guó)心臟協(xié)會(huì)／美國(guó)卒中學(xué)會(huì)（American Heart Association/American Stroke Association，AHA/ASA）評(píng)選出2011年全球腦血管病最重要的十大研究進(jìn)展中，與心房顫動(dòng)相關(guān)的卒中占了三席，包括心房顫動(dòng)的危險(xiǎn)因素[74]、心房顫動(dòng)患者的降壓藥物選擇[75]及新型口服抗凝藥物[31-36]，成為2011年卒中研究領(lǐng)域最搶眼的熱點(diǎn)。大約有1/5的卒中是由心房顫動(dòng)所致，未被診斷的心房顫動(dòng)即無(wú)癥狀性心房顫動(dòng)很可能是原因不明卒中的病因。心房顫動(dòng)所致的卒中相對(duì)嚴(yán)重，會(huì)導(dǎo)致長(zhǎng)期的殘疾或死亡。心房顫動(dòng)作為心源性卒中最常見的原因，提高其檢出率，指導(dǎo)一級(jí)預(yù)防、二級(jí)預(yù)防及預(yù)后評(píng)估對(duì)于卒中醫(yī)療質(zhì)量改進(jìn)及提高患者生活質(zhì)量意義重大，任重而道遠(yuǎn)。

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【點(diǎn)睛】

本文介紹了心房顫動(dòng)患者卒中風(fēng)險(xiǎn)、出血風(fēng)險(xiǎn)、預(yù)后等方面預(yù)測(cè)模型和評(píng)分系統(tǒng)的發(fā)展和現(xiàn)狀。