追加：第 1 节第 44 条，心慌、心跳乱就去做心电图，查出房颤请医生评估吃抗凝药防中风

2026-10-14 起草。全书原来没有房颤抗凝的条目，只有第 2 节第 26 条（咖啡）备注里提到房颤复发。追加在第 1 节末尾，条号暂定 44。节首导览建议挂进「筛查和查病」一块，短名「查出房颤吃抗凝药」。

和已有条目的分工

  • 本节第 7 条（量血压）管高血压。高血压是房颤中风打分里的一项，本条只指路过去。
  • 第 2 节第 12 条（高血压、高血脂按医嘱吃药）和第 16 节第 1 条（药按医嘱吃满）管长期吃药的依从性，本条只写「别觉得没事就停」并指到第 16 节第 1 条。
  • 第 13 节第 3 条（突然嘴歪、一侧胳膊没劲）管中风发作时的急救，本条管发作之前的预防。
  • 第 34 节第 3 条（在吃抗凝药的人吃布洛芬之前先问医生）管吃上抗凝药之后的止痛药，本条指过去。
  • 第 2 节第 26 条（咖啡）备注写了有房颤的人不必一律戒咖啡，本条指过去，不重复。

证据等级与收益量级

  • 证据等级 A：抗凝药对不吃药的效果来自随机试验的荟萃分析（Hart 2007，29 项试验）和 Cochrane 综述，新药对华法林来自 4 项三期试验合并（Ruff 2014），都有具体的相对风险。
  • 标「争议」：争议只在「没症状的人要不要专门去筛查」这一侧。美国预防服务工作组 2022 年给 I 声明（证据不足），STROKESTOP 综合终点 HR 0.96 刚好显著，LOOP 中风 HR 0.80 不显著。查出房颤后按风险吃抗凝药，中美指南一致，没有争议。备注以「争议」开头，按 sync-stats 的口径会计入争议数。
  • 收益量级「大」：按死亡率口径机械套。Cochrane 综述里华法林对不吃药的死亡 OR 0.69（低 31%），≥20% 为大。中风降 64% 更大。
  • 成本标签：钱=少（心电图几十元，华法林便宜，新型抗凝药贵一些，都是作者估计，没写具体药价）；时间=少；毅力=些（要天天吃、要定期抽血或复诊）。没加人群标签：房颤不在 7 个值里，高血压条也没加。

1. Hart RG, Pearce LA, Aguilar MI (2007), Ann Intern Med 146(12):857-867

  • DOI：https://doi.org/10.7326/0003-4819-146-12-200706190-00007（PMID 17577005；Europe PMC 摘要。acpjournals.org 全文是 Cloudflare 质询，curl 和无头 Chrome 都没取到，所以总死亡率改从 Cochrane 综述取）
  • 「Twenty-nine trials included 28,044 participants (mean age, 71 years; mean follow-up, 1.5 years).」
  • 「Compared with the control, adjusted-dose warfarin (6 trials, 2900 participants) and antiplatelet agents (8 trials, 4876 participants) reduced stroke by 64% (95% CI, 49% to 74%) and 22% (CI, 6% to 35%), respectively.」
  • 「Adjusted-dose warfarin was substantially more efficacious than antiplatelet therapy (relative risk reduction, 39% [CI, 22% to 52%]) (12 trials, 12 963 participants).」
  • 「Absolute increases in major extracranial hemorrhage were small (< or =0.3% per year) on the basis of meta-analysis.」

2. Aguilar MI, Hart R (2005), Cochrane CD001927.pub2

  • DOI：https://doi.org/10.1002/14651858.CD001927.pub2（PMID 16034869，Europe PMC 摘要）
  • 「Of 2313 participants without prior cerebral ischemia from five randomized trials, the mean age was 69 years.」
  • 「warfarin was associated with large, highly statistically significant reductions in all strokes (odds ratio (OR) 0.39, 95% confidence interval (CI) 0.26 to 0.59) ... death (OR 0.69, 95% CI 0.50 to 0.94)」
  • 机制：「Non-valvular atrial fibrillation (AF) is associated with an increased risk of stroke mediated by embolism of stasis-precipitated thrombi from the left atrial appendage.」条目里「血在心房里淤住，容易结成血块，冲进脑血管就是中风」出自这句。
  • 只含没中过风、没有过短暂脑缺血的人，条目写明「只看没中过风的」。

3. Ruff CT 等 (2014), Lancet 383(9921):955-962

  • DOI：https://doi.org/10.1016/S0140-6736(13)62343-0（PMID 24315724）
  • 「We did a prespecified meta-analysis of all 71,683 participants included in the RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE AF-TIMI 48 trials.」
  • 「New oral anticoagulants significantly reduced stroke or systemic embolic events by 19% compared with warfarin (RR 0·81, 95% CI 0·73-0·91; p<0·0001)」
  • 「New oral anticoagulants also significantly reduced all-cause mortality (0·90, 0·85-0·95; p=0·0003) and intracranial haemorrhage (0·48, 0·39-0·59; p<0·0001), but increased gastrointestinal bleeding (1·25, 1·01-1·55; p=0·04).」

4. Connolly SJ 等 (2011), AVERROES, N Engl J Med 364(9):806-817

  • DOI：https://doi.org/10.1056/NEJMoa1007432（PMID 21309657）
  • 「we randomly assigned 5599 patients with atrial fibrillation who were at increased risk for stroke and for whom vitamin K antagonist therapy was unsuitable to receive apixaban ... or aspirin (81 to 324 mg per day)」
  • 「hazard ratio with apixaban, 0.45; 95% confidence interval [CI], 0.32 to 0.62; P<0.001」
  • 「There were 44 cases of major bleeding (1.4% per year) in the apixaban group and 39 (1.2% per year) in the aspirin group (hazard ratio with apixaban, 1.13; 95% CI, 0.74 to 1.75; P=0.57)」

5. Mant J 等 (2007), BAFTA, Lancet 370(9586):493-503

  • DOI：https://doi.org/10.1016/S0140-6736(07)61233-1（PMID 17693178）
  • 「973 patients aged 75 years or over (mean age 81.5 years, SD 4.2) with atrial fibrillation were recruited from primary care and randomly assigned to warfarin ... or aspirin (75 mg per day).」
  • 主要终点：「fatal or disabling stroke (ischaemic or haemorrhagic), intracranial haemorrhage, or clinically significant arterial embolism」
  • 「yearly risk 1.8%vs 3.8%, relative risk 0.48, 95% CI 0.28-0.80, p=0.003」
  • 「Yearly risk of extracranial haemorrhage was 1.4% (warfarin) versus 1.6% (aspirin) (relative risk 0.87, 0.43-1.73 ...)」

6. 中国房颤指南英文版：Ma CS 等 (2024), J Geriatr Cardiol 21(3):251-314

  • DOI：https://doi.org/10.26599/1671-5411.2024.03.009；全文 https://pmc.ncbi.nlm.nih.gov/articles/PMC11040055/（2026-10-14 带代理取到）。中文原版是《中华心血管病杂志》2023 年 51(6) 期，DOI 10.3760/cma.j.cn112148-20230416-00221，原文没取到，按英文版核对。
  • 症状：「The most common symptoms of AF are palpitations, decreased exercise tolerance, and chest discomfort.」；「Approximately, 25% patients self-report being asymptomatic.」
  • 诊断：「AF can be diagnosed when a single-lead electrocardiogram (ECG) (≥ 30 s) or a 12-lead ECG (≥ 10 s) shows the disappearance of P waves」
  • 打分（Table 5, CHA2DS2-VASc-60）：Congestive HF 1；Hypertension 1；「Age ≥ 65 yrs Asian patients with AF aged ≥ 65 years 2」；Diabetes mellitus 1；Stroke（含 TIA、体循环栓塞）2；Vascular disorders 1；「Age 60–64 yrs ... 1」；「Sex (Female) A modifier for stroke risk, but not an independent risk factor 1」。
  • 「It is recommended that male AF patients with a CHA 2 DS 2 -VASc-60 score of ≥ 2, or female AF patients with a score of ≥ 3, should use oral anticoagulants.」
  • 「Male patients with a CHA 2 DS 2 -VASc-60 score of 1 and female patients with a score of 2 should also consider using oral anticoagulants after weighing the expected stroke risk, bleeding risk, and patient preferences.」
  • 「Monotherapy with antiplatelet drugs does not reduce the risk of stroke in patients with AF.」；「Therefore, antiplatelet therapy is not recommended for the prevention of AF-related stroke.」
  • 筛查：「Opportunistic screening for AF can be considered in individuals aged ≥ 65 years during medical visits, using methods such as pulse palpation or electrocardiography.」同一节也写了「Opportunistic screening using the single-lead ECG or combined with pulse palpation and blood pressure measurement in individuals aged ≥ 65 years did not significantly increase the detection rate of AF.」所以备注写「可以考虑」，没写成「推荐」。
  • 注意：指南说「单用抗血小板药不降低中风风险」，Hart 2007 的数字是降 22%（可信范围 6% 到 35%）。两者不完全一致，条目收益栏如实写 Hart 的数字，同时写指南不推荐，说人话写「只少约两成，代替不了」。

7. Joglar JA 等 (2024), 2023 ACC/AHA/ACCP/HRS 房颤指南, Circulation 149(1):e1-e156

  • DOI：https://doi.org/10.1161/CIR.0000000000001193；全文 https://pmc.ncbi.nlm.nih.gov/articles/PMC11095842/（Europe PMC 的 fullTextXML 接口返回 500，改从 PMC 页面取）
  • 「In patients diagnosed with AF who have an estimated annual risk of stroke or thromboembolic events ≥2%, selection of therapy to reduce the risk of stroke should be based on the risk of thromboembolism, regardless of whether the AF pattern is paroxysmal, persistent, long-standing persistent, or permanent.」
  • 「In patients who are deemed at high risk for stroke, bleeding risk scores should not be used in isolation to determine eligibility for oral anticoagulation but instead to identify and modify bleeding risk factors and to inform medical decision-making.」
  • 「In patients with AF who are candidates for anticoagulation and without an indication for antiplatelet therapy, aspirin either alone or in combination with clopidogrel as an alternative to anticoagulation is not recommended to reduce stroke risk.」（条目没单独引这句，「阿司匹林代替不了」由 AVERROES、BAFTA 和中国指南支撑，这句作旁证。）

8. Du X 等 (2021), Heart（中国高血压调查房颤部分）

  • DOI：https://doi.org/10.1136/heartjnl-2020-317915（PMID 33509976，PMC7958113）。卷期页 Europe PMC 题录里没有，来源栏只写到期刊名，没凭记忆补。
  • 「We conducted a community-based survey of 47 841 adults (age ≥45 years) in seven geographic regions of China between 2014 and 2016.」
  • 「The weighted AF prevalence was 1.8% (95% CI 1.7% to 1.9%) ... and equates to being present in an estimated 7.9 (95% CI 7.4 to 8.4) million people in China.」条目写「约 790 万人」。
  • 「residency status (urban 78.3%, rural 35.3%)」（知道自己有房颤的比例）
  • 「Only 6.0% of patients with high-risk AF received anticoagulation therapy.」

9. Shi S 等 (2022), Lancet Reg Health West Pac 23:100439

  • DOI：https://doi.org/10.1016/j.lanwpc.2022.100439（PMC9252928，Europe PMC 全文 XML）
  • 「Study data were derived from a national sample from July 2020 to September 2021.」
  • 「Among participants with AF, 1,463 (56·2%) cases had a medical history of AF and 1,141 (43·8%) cases of newly diagnosed AF」
  • 「32·1% of patients received anticoagulation therapy, and the anticoagulation rate was higher in urban areas than that in rural areas (390 [36·6%] vs 79 [19·8%]; p < 0·001, Appendix 5).」这句紧跟在「Among participants previously diagnosed with AF」之后，(390+79)/1463 = 32.06%，所以分母是以前就确诊的人，条目写「以前就确诊的人里」。

10. USPSTF (2022), JAMA 327(4):360-367

11. Svennberg E 等 (2021), STROKESTOP, Lancet 398(10310):1498-1506

  • DOI：https://doi.org/10.1016/S0140-6736(21)01637-8（PMID 34469764）
  • 「All 75-76-year-olds residing in these two regions were randomly assigned (1:1) to be invited to screening」；「register intermittent electrocardiograms (ECGs) for 14 days」
  • 主要终点：「ischaemic or haemorrhagic stroke, systemic embolism, bleeding leading to hospitalisation, and all-cause death」
  • 「After a median follow-up of 6·9 years ... hazard ratio 0·96 [95% CI 0·92-1·00]; p=0·045」。条目写「约 7 年后……只少 4%，刚够上统计差别」。
  • 只有 51.3% 的受邀者来参加（「7165 (51·3%) of 13 979 participated」），条目没写。

12. Svendsen JH 等 (2021), LOOP, Lancet 398(10310):1507-1516

  • DOI：https://doi.org/10.1016/S0140-6736(21)01698-6（PMID 34469766）
  • 「We included individuals without atrial fibrillation, aged 70-90 years, with at least one additional stroke risk factor」
  • 「atrial fibrillation was diagnosed in 1027 participants: 477 (31·8%) of 1501 in the ILR group versus 550 (12·2%) of 4503 in the control group」
  • 「the primary outcome occurred in ... 67 (4·5%) in the ILR group versus 251 (5·6%) in the control group (HR 0·80 [95% CI 0·61-1·05]; p=0·11)」
  • 作者解读：「These findings might imply that not all atrial fibrillation is worth screening for, and not all screen-detected atrial fibrillation merits anticoagulation.」

没收的内容和理由

  • ESC 2024 房颤指南（Van Gelder, Eur Heart J, DOI 10.1093/eurheartj/ehae176）：academic.oup.com 是 Cloudflare 质询，curl 和无头 Chrome 都没取到原文，65 岁以上机会性筛查改引能逐字核对的中国指南。
  • China-AF 登记（Chang SS 2016, Stroke 47(7):1803-1810, DOI 10.1161/STROKEAHA.116.012988）：北京 32 家医院 2011 到 2014 年，CHA2DS2-VASc ≥2 的人 36.5% 在用口服抗凝药。只是北京医院病人，比全国社区调查偏高，条目用 Du 2021 和 Shi 2022 两份全国数据，这份没写。
  • 药价：华法林、新型抗凝药集采后的单价没有逐字核到官方来源，成本栏只写「华法林很便宜」「新型抗凝药贵一些」，没写数字。
  • 左心耳封堵：美国指南写了出血风险高的人可以考虑，离普通读者远，没写。
  • 智能手表筛查：两份指南都只说有潜力，没有硬终点，没写。