Spyropoulos A C, Turpie A G G, Dunn A S, Spandorfer J, Douketis J, Jacobson A, Frost F J
Lovelace Medical Center, Albuquerque, NM 87108, USA.
J Thromb Haemost. 2006 Jun;4(6):1246-52. doi: 10.1111/j.1538-7836.2006.01908.x.
Patients who receive long-term oral anticoagulant (OAC) therapy often require interruption of OAC for an elective surgical or an invasive procedure. Heparin bridging therapy has been used in these situations, although the optimal method has not been established. No large prospective studies have compared unfractionated heparin (UFH) with low-molecular-weight heparin (LMWH) for the perioperative management of patients at risk of thromboembolism requiring temporary interruption of long-term OAC therapy.
PATIENTS/METHODS: This multicenter, observational, prospective registry conducted in North America enrolled 901 eligible patients on long-term OAC who required heparin bridging therapy for an elective surgical or invasive procedure. Practice patterns and clinical outcomes were compared between patients who received either UFH alone (n = 180) or LMWH alone (n = 721).
Overall, the majority of patients (74.5%) requiring heparin bridging therapy had arterial indications for OAC. LMWH, in mostly twice-daily treatment doses, represented approximately 80% of the study population. LMWH-bridged patients had significantly fewer arterial indications for OAC, a lower mean Charlson comorbidity score, and were less likely to undergo major or cardiothoracic surgery, receive intraprocedural anticoagulants or thrombolytics, or receive general anesthesia than UFH-bridged patients (all P < 0.05). The LMWH group had significantly more bridging therapy completed in an outpatient setting or with a < 24-h hospital stay vs. the UFH group (63.6% vs. 6.1%, P < 0.001). In the LMWH and UFH groups, similar rates of overall adverse events (16.2% vs. 17.1%, respectively, P = 0.81), major composite adverse events (arterial/venous thromboembolism, major bleed, and death; 4.2% vs. 7.9%, respectively, P = 0.07) and major bleeds (3.3% vs. 5.5%, respectively, P = 0.25) were observed. The thromboembolic event rates were 2.4% for UFH and 0.9% for LMWH. Logistic regression analysis revealed that for postoperative heparin use a Charlson comorbidity score > 1 was an independent predictor of a major bleed and that vascular, general, and major surgery were associated with non-significant trends towards an increased risk of major bleed.
Treatment-dose LMWH, mostly in the outpatient setting, is used substantially more often than UFH as bridging therapy in patients with predominately arterial indications for OAC. Overall adverse events, including thromboembolism and bleeding, are similar for patients treated with LMWH or UFH. Postoperative heparin bridging should be used with caution in patients with multiple comorbidities and those undergoing vascular, general, and major surgery. These findings need to be confirmed using large randomized trials for specific patient groups undergoing specific procedures.
接受长期口服抗凝剂（OAC）治疗的患者在进行择期手术或侵入性操作时通常需要中断OAC治疗。在这些情况下会使用肝素桥接治疗，尽管尚未确定最佳方法。尚无大型前瞻性研究比较普通肝素（UFH）与低分子量肝素（LMWH）用于需要暂时中断长期OAC治疗的血栓栓塞风险患者的围手术期管理。
患者/方法：这项在北美进行的多中心、观察性、前瞻性登记研究纳入了901例接受长期OAC治疗且因择期手术或侵入性操作需要肝素桥接治疗的符合条件的患者。比较了单独接受UFH（n = 180）或单独接受LMWH（n = 721）的患者的治疗模式和临床结局。
总体而言，需要肝素桥接治疗的大多数患者（74.5%）有OAC的动脉指征。LMWH大多采用每日两次的治疗剂量，约占研究人群的80%。与接受UFH桥接的患者相比，接受LMWH桥接的患者OAC的动脉指征明显更少，平均Charlson合并症评分更低，接受大手术或心胸外科手术、术中接受抗凝剂或溶栓剂或接受全身麻醉的可能性更小（所有P < 0.05）。与UFH组相比，LMWH组在门诊环境或住院时间< 24小时的情况下完成桥接治疗的比例明显更高（63.6%对6.1%，P < 0.001）。在LMWH组和UFH组中，总体不良事件发生率相似（分别为16.2%和17.1%，P = 0.81），主要复合不良事件（动脉/静脉血栓栓塞、大出血和死亡；分别为4.2%和7.9%，P = 0.07）和大出血发生率相似（分别为3.3%和5.5%，P = 0.25）。UFH的血栓栓塞事件发生率为2.4%，LMWH为0.9%。逻辑回归分析显示，对于术后使用肝素，Charlson合并症评分> 1是大出血的独立预测因素，血管手术、普通手术和大手术与大出血风险增加的非显著趋势相关。
在以动脉指征为主的OAC患者中，治疗剂量的LMWH（大多在门诊环境中使用）作为桥接治疗比UFH使用得更为频繁。接受LMWH或UFH治疗的患者的总体不良事件，包括血栓栓塞和出血，相似。对于有多种合并症的患者以及接受血管手术、普通手术和大手术的患者，术后肝素桥接应谨慎使用。这些发现需要通过针对接受特定手术的特定患者群体的大型随机试验来证实。
