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.

背景与研究目标：探讨拉丁美洲范围内的脑卒中（stroke）危险因素，包括心房颤动（atrial fibrillation）的管理与预防方案，以及脑卒中预后情况。研究设计与实施场景：在美国皮埃蒙特心脏研究所开展的叙述性综述。研究方法：检索PubMed、Embase及Cochrane数据库中2009年1月至2015年3月期间收录的以脑卒中（stroke）、“拉丁美洲”及流行病学为主题的文献；另外通过SciELO、世界卫生组织（World Health Organization）及泛美卫生组织（Pan-American Health Organization）数据库补充检索相关文献，以针对特定研究要点展开分析。研究结果：世界银行归类为低收入或中等收入的国家（涵盖拉丁美洲多数地区），其脑卒中病例数占全球总病例数的三分之二。全球范围内，仅不足半数的心房颤动（atrial fibrillation）患者接受了可有效降低脑卒中风险的规范抗凝治疗（anticoagulation），中位达标率为43.9%；这一数据与拉丁美洲的统计结果相符：该地区整体有46%的门诊患者未接受符合指南要求的抗凝治疗，其中巴西的未接受比例为41.8%，哥伦比亚则为54.8%。研究结论：心房颤动相关性脑卒中负担沉重。非维生素K拮抗剂类口服抗凝药（non-vitamin K antagonist oral anticoagulants）为降低心房颤动相关性脑卒中风险提供了治疗选择。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（warfarin）的成本效益对比研究。针对拉丁美洲地区，应在推进脑卒中危险因素干预及基于指南的预防工作的同时，出台相关举措以消除医疗公平差距、提升医疗服务可及性。