Rubboli Andrea, Colletta Mauro, Herzfeld Jessica, Sangiorgio Pietro, Di Pasquale Giuseppe
Division of Cardiology, Maggiore Hospital, Bologna, Italy, and School of Medicine, Karolinska University, Stockholm, Sweden.
Coron Artery Dis. 2007 May;18(3):193-9. doi: 10.1097/MCA.0b013e328012a964.
The optimal antithrombotic treatment for patients on long-term anticoagulation undergoing invasive coronary procedures is currently undefined. The strategies adopted periprocedurally and medium-term after coronary stenting (percutaneous coronary intervention with stent implantation) at our Institution, were reviewed, and the safety and efficacy of the various regimens evaluated.
All patients undergoing invasive coronary procedures between January 2002 and December 2004 were retrospectively identified.
Out of 3709 patients overall, 104 (2.8%; 95% confidence interval 2.3-3.4) were on warfarin (because of atrial fibrillation in >50% of cases), whereas this was the case for 49 (3.1%; 95% confidence interval 2.3-4.1) of 1584 undergoing percutaneous coronary intervention with stent implantation. The antithrombotic strategies were highly variable, both periprocedurally (i.e. warfarin withdrawal or substitution by heparin, followed by aspirin with or without a thienopyridine) and medium-term after percutaneous coronary intervention with stent implantation (i.e. combination of warfarin and single or dual antiplatelet agents or pure dual antiplatelet treatment). Overall, periprocedural hemorrhages occurred in five patients (4.8%; 95% confidence interval 1.56-11.22). No thromboembolic events were observed, whereas one subacute stent thrombosis occurred (2%; 95% confidence interval 0.05-11) during warfarin and aspirin treatment. Among patients undergoing percutaneous coronary intervention with stent implantation, 1-month hemorrhagic rate was 10% (95% confidence interval, 3.3-23.8); most hemorrhages (major bleeds in three-quarters of cases) occurred during triple therapy with warfarin (or low-molecular-weight heparin), aspirin and a thienopyridine.
At our Institution (where standardized protocols are currently not in use), periprocedural and medium-term antithrombotic treatment in patients on long-term anticoagulation undergoing percutaneous coronary intervention with stent implantation showed substantial variability. As a result of the relevant 1-month complication rate, further properly sized and designed studies are warranted to identify the optimal strategies for this patient subset, which is foreseen to progressively increase over the next years.
目前，对于接受侵入性冠状动脉手术的长期抗凝患者，最佳抗血栓治疗方案尚不明确。我们回顾了本院在冠状动脉支架置入术（经皮冠状动脉介入并植入支架）围手术期及中期所采用的策略，并评估了各种方案的安全性和有效性。
对2002年1月至2004年12月期间接受侵入性冠状动脉手术的所有患者进行回顾性分析。
在总共3709例患者中，104例（2.8%；95%置信区间2.3 - 3.4）正在服用华法林（超过50%的病例因房颤），而在1584例接受经皮冠状动脉介入并植入支架的患者中，有49例（3.1%；95%置信区间2.3 - 4.1）正在服用华法林。抗血栓策略在围手术期（即停用华法林或用肝素替代，随后使用阿司匹林，加或不加噻吩并吡啶）以及经皮冠状动脉介入并植入支架后的中期（即华法林与单种或双重抗血小板药物联合使用或单纯双重抗血小板治疗）差异很大。总体而言，围手术期有5例患者发生出血（4.8%；95%置信区间1.56 - 11.22）。未观察到血栓栓塞事件，而在华法林和阿司匹林治疗期间发生了1例亚急性支架血栓形成（2%；95%置信区间0.05 - 11）。在接受经皮冠状动脉介入并植入支架的患者中，1个月时的出血率为10%（95%置信区间3.3 - 23.8）；大多数出血（四分之三的病例为大出血）发生在华法林（或低分子肝素）、阿司匹林和噻吩并吡啶三联治疗期间。
在我们医院（目前未使用标准化方案），接受经皮冠状动脉介入并植入支架的长期抗凝患者的围手术期和中期抗血栓治疗差异很大。鉴于相关的1个月并发症发生率，有必要开展进一步规模合适且设计合理的研究，以确定该患者亚组的最佳策略，预计在未来几年该患者亚组人数将逐渐增加。
