从维生素K拮抗剂转换为直接口服抗凝药治疗体弱老年心房颤动患者：系统评价与荟萃分析。
完整摘要 · 中文译文
背景：衰弱会使老年心房颤动（房颤）患者的抗凝管理复杂化，尤其是在已长期使用维生素K拮抗剂（VKA）治疗的情况下。在这一人群中，改用直接口服抗凝药（DOAC）是否能改善结局仍不确定，且指南推荐有限。我们开展了一项系统评价和荟萃分析，比较衰弱的老年房颤患者中由VKA转换为DOAC与继续使用VKA的结局。方法：系统检索了MEDLINE、Scopus和Cochrane Library，检索时间从建库至2026年4月4日。纳入标准为：纳入正在接受VKA治疗且衰弱的老年房颤患者，并直接比较转换为DOAC与继续VKA治疗的研究。主要结局为卒中/体循环栓塞、大出血或全因死亡的复合结局。采用三水平随机效应模型合并调整后的风险比（HR）。结果：共纳入4项研究（5个治疗比较），包含57,099例患者。总体而言，与继续VKA治疗相比，由VKA转换为DOAC治疗与复合结局无显著差异（HR 1.18，95% CI 0.84-1.67）。在大出血（HR 1.13，95% CI 0.80-1.60）、血栓栓塞（HR 1.03，95% CI 0.63-1.68）或全因死亡（HR 0.95，95% CI 0.77-1.16）方面也未观察到显著差异。在仅限定于随机试验的分析中，所有结局仍为中性结果。结论：在接受VKA治疗的衰弱老年房颤患者中，转换至 与继续使用维生素K拮抗剂（VKA）治疗相比，改用直接口服抗凝药（DOAC）并未显著降低血栓栓塞、大出血、死亡率或复合结局。
完整摘要 · 英文原文
Background: Frailty complicates anticoagulation management in older patients with atrial fibrillation (AF), particularly when long-term vitamin K antagonist (VKA) therapy is already established. Whether switching to a direct oral anticoagulant (DOAC) improves outcomes in this setting remains uncertain, and guideline recommendations are limited. We performed a systematic review and meta-analysis comparing outcomes of VKA-to-DOAC switching versus VKA continuation in frail elderly patients with AF. Methods: MEDLINE, Scopus, and the Cochrane Library were systematically searched from inception through 4 April 2026. Studies enrolling frail elderly patients with AF receiving VKA therapy and directly comparing switching to a DOAC versus continued VKA treatment were eligible. The primary outcome was a composite of stroke/systemic embolism, major bleeding, or all-cause mortality. Adjusted hazard ratios (HRs) were pooled using three-level random-effects models. Results: Four studies (five treatment comparisons) comprising 57,099 patients were included. Overall, switching from VKA to DOAC therapy was not associated with a significant difference in the composite outcome compared with continued VKA treatment (HR 1.18, 95% CI 0.84-1.67). No significant differences were observed for major bleeding (HR 1.13, 95% CI 0.80-1.60), thromboembolism (HR 1.03, 95% CI 0.63-1.68), or all-cause mortality (HR 0.95, 95% CI 0.77-1.16). In analyses restricted to randomized trials, results remained neutral across all outcomes. Conclusion: In frail elderly patients with AF receiving VKA therapy, switching to a DOAC was not associated with significant reductions in thromboembolism, major bleeding, mortality, or the composite outcome compared with continued VKA treatment.