Targeting stroke risk and improving outcomes in patients with atrial fibrillation in Latin America

ABSTRACT CONTEXT AND OBJECTIVE: To examine stroke risk factors, including atrial fibrillation, management and prevention, and stroke outcomes across Latin America. DESIGN AND SETTING: Narrative review conducted at Piedmont Heart Institute, United States. METHODS: The PubMed, Embase and Cochrane databases were searched for stroke AND "Latin America" AND epidemiology (between January 2009 and March 2015). Further studies in the SciELO, World Health Organization and Pan-American Health Organization databases were used to address specific points. RESULTS: Countries categorized as low or middle-income nations by the World Bank, which includes most of Latin America, account for two-thirds of all strokes. Globally, fewer than half of patients (median treatment level: 43.9%) with atrial fibrillation receive adequate anticoagulation to reduce stroke risk, which correlates with data from Latin America, where 46% of outpatients did not receive guideline-compliant anticoagulation, ranging from 41.8% in Brazil to 54.8% in Colombia. CONCLUSIONS: Atrial fibrillation-related stroke carries a heavy burden. Non-vitamin K antagonist oral anti-coagulants provide options for reducing the risk of atrial fibrillation-related stroke. However, cost-effectiveness comparisons with warfarin are warranted before observational health-economics study results can be applied clinically. Initiatives to remedy inequalities and improve access to care across Latin America should accompany risk factor modification and guideline-based prevention.

【研究背景与目标】本研究旨在探讨拉丁美洲地区的脑卒中危险因素（涵盖心房颤动）、诊疗与预防方案，以及脑卒中预后情况。【研究设计与实施场景】本研究为叙事性综述，实施于美国皮埃蒙特心脏研究所（Piedmont Heart Institute）。【研究方法】检索PubMed、Embase及Cochrane数据库，检索主题为"脑卒中 AND 拉丁美洲 AND 流行病学"，检索时限为2009年1月至2015年3月。此外，通过SciELO、世界卫生组织（World Health Organization）及泛美卫生组织（Pan-American Health Organization）数据库补充检索针对特定研究议题的相关文献。【研究结果】世界银行（World Bank）划定的中低收入国家（涵盖拉丁美洲多数国家），承担了全球三分之二的脑卒中疾病负担。全球范围内，仅不足半数的心房颤动患者（中位治疗比例：43.9%）接受了可有效降低脑卒中风险的充分抗凝治疗；这一数据与拉丁美洲地区的调研结果相符：该地区46%的门诊患者未接受符合指南要求的抗凝治疗，其中巴西该比例为41.8%，哥伦比亚则高达54.8%。【研究结论】与心房颤动相关的脑卒中疾病负担沉重。非维生素K拮抗剂类口服抗凝药为降低心房颤动相关脑卒中风险提供了新的治疗选择，但在将观察性卫生经济学研究结果应用于临床实践前，仍需开展其与华法林的成本效益对比研究。此外，需推出相关举措以改善拉丁美洲地区的医疗公平性与可及性，同时配合危险因素干预与基于指南的脑卒中预防方案。