摘要
目的 通过观察心血管植入型电子器械（CIED）围术期不同抗栓治疗方案术后出血事件的发生率,探讨CIED植入围术期更加安全可靠的治疗策略.方法 观察2011年12月至2016年7月山西医科大学附属大医院心内科符合CIED植入适应证并于住院期间成功植入CIED的患者资料,分析术后囊袋血肿等出血事件的危险因素.结果 350例患者,平均年龄23~95（68.3±13.1）岁,男202例（57.7%）,其中围术期不中断华法林患者27例（7.7%）;低分子肝素（LMWH）桥接抗凝患者61例（17.4%）;不中断阿司匹林（ASA）患者17例（4.9%）;不中断ASA合用氯吡格雷患者24例（6.9%）;围术期停用抗栓药物7 d以上或未应用影响凝血功能药物患者221例（63.1%）.需处理的囊袋血肿6例（1.7%）,其中非抗栓组1例（0.45%）,LMWH组4例（6.55%）,ASA组1例（5.88%）,华法林组及双联抗血小板治疗（DAP）组无囊袋血肿发生,LMWH组与非抗栓组差异有统计学意义（P=0.008）;其余各抗栓亚组与非抗栓组差异无统计学意义（P〉0.1）.出血患者体质指数（BMI）低于非出血患者[（19.6±2.3）对（23.2 ± 2.2）,P=0.033],较非出血组合并心力衰竭较多（66.7%对7.6%,P〈0.001）.多因素分析中体型消瘦及LMWH桥接为预测出血事件发生的危险因素[（OR 4.3234,95%CI 1.8319~16.9838）与（OR 3.3901,95%CI 1.8401~18.4390）].结论 ①正在接受华法林、ASA或DAP的患者术前可继续抗栓治疗;②LMWH桥接抗凝增加囊袋血肿发生率,应弃用;③围术期中断抗凝治疗可能增加患者血栓栓塞事件的发生;④体型消瘦、心力衰竭患者术后易发生出血并发症.
Objective To evaluate the suitable strategies of antithrombotic therapy for patients with cardiovascular implantable electronic devices（CIED）in the peri-procedure period. Methods Clinical charac-teristics and anticoagulant/antiplatelet drugs in 350 patients[age,23-95（68.3±13.1）years;males 57.7%]im-planted with CIED were evaluated and analyzed retrospectively. Results There were 27 cases（7.7%）who continued the warfarin during peri-operation,61 cases（17.4%）bridged with low-molecular-weight heparin（LM-WH）,17 cases（4.9%）continued aspirin（ASA）,24 cases（6.9%）continued aspirin plus clopidogrel,221 ca-ses（63.1%）interrupted antithrombotic drugs more than 7 days or didn＇t use the drugs which might affect blood coagulation function.Of these,6 patients（1.7%）experienced a hematoma at pacemaker pocket and nee-ded hematoma evacuation,four of them were to bridge LMWH.The frequency of hematoma was significantly higher（P=0.008）in patients who bridged to LMWH.ASA alone,dual antiplatelet（DAP）therapy,and warfa-rin did not increase the risk of hematoma（P〉0.1）.The body mass index（BMI）in the patients with hematoma was less than that in patients without hematoma[（19.6±2.3）vs.（23.2±2.2）,P=0.033）].Heart failure in-creased the risk of bleeding（66.7% vs.7.6%,P〈0.001）.Logistic regression analysis model was established and showed that hematoma was increased by 3.39（95% CI 3.39-1.84）times in the bridging therapy group,and 4.32（95% CI,4.32~1.83）in patients with a low BMI. Conclusion ①Warfarin,aspirin or DAP shouldn＇t be interrupted before the CIED implantation.②Bridging by LMWH should be abandoned because it could in-crease the risk of hematoma seriously in the peri-procedure period.③Patient might associate with a higher risk of perioperative thromboembolic events during anticoagulant therapy interruption.④Patients with emaciation or heart failure might suffer high risk of hematoma.
出处
《中华心律失常学杂志》
2017年第5期397-400,420,共5页
Chinese Journal of Cardiac Arrhythmias
