Ambrosetti Marco, Ageno Walter, Calori Alberto, Ferrarese Sandro, Barosi Annalisa, Marchetti Paolo, Salvato Luciano, Sala Andrea
Cardiovascular Rehabilitation Unit, Le Terrazze Clinic, Cunardo, VA, Italy.
Monaldi Arch Chest Dis. 2009 Mar;72(1):29-32. doi: 10.4081/monaldi.2009.340.
In patients undergoing heart valve surgery (HVS) who require warfarin therapy, the maintenance of low variability in the level of anticoagulation early after operation is generally difficult. Aim of this study was to evaluate the time in therapeutic range (TTR) in HVS patients receiving oral anticoagulation therapy (OAT) during phase I-II of cardiac rehabilitation (CR), and, secondly, to identify clinical variables associated with inadequate anticoagulation.
Observational study of consecutive in-hospital patients directly tracked from a cardiac surgery unit to a CR facility. OAT was monitored both in terms of administered warfarin doses and resulted INR values, from day 1 to day 15 after operation. Clinical variables were tested in a logistic regression model for the prediction of inadequate anticoagulation, defined as the presence of nontherapeutic INRs for > or = 5 days between day 8 and 15.
Eighty-one patients (males 56%, age 62 +/- 19 yrs.), following valvuloplasty (37%), mechanical (17%), and bioprosthetic (45%) valve replacement were considered. The prescribed warfarin dosages were significantly higher from day 1 to day 7 than from day 8 to day 15 (4.6 +/- 3.6 and 3.0 +/- 1.1 mg respectively, p< 0.001). Overall, TTR was 6 +/- 3 days, while time with elevated and lower INRs accounted for 1.3 +/- 1.6 and 8.0 +/- 3.5 days respectively. At day 7, only 25% of patients (n= 20) showed a therapeutic INR value. Inadequate anticoagulation between postoperative day 8 and 15 was displayed in 41 (51%) patients, with hypertension as the only independent predictor (p< 0.001) at multivariate analysis.
Despite intensive monitoring, half of patients have nontherapeutic INR values (mainly subtherapeutic) in the first two weeks after HVS while on warfarin. Giving the high risk of completing the hospitalization phase without a stable OAT in many patients, both cardiac surgeons and cardiologists should not miss the opportunity to improve patients education, and consider a direct track to anticoagulation management services after discharge.
在接受心脏瓣膜手术（HVS）且需要华法林治疗的患者中，术后早期维持抗凝水平的低变异性通常很困难。本研究的目的是评估心脏康复（CR）I-II期接受口服抗凝治疗（OAT）的HVS患者的治疗范围内时间（TTR），其次，确定与抗凝不足相关的临床变量。
对从心脏外科病房直接追踪至CR机构的连续住院患者进行观察性研究。从术后第1天至第15天，对华法林给药剂量和由此产生的国际标准化比值（INR）值进行监测。在逻辑回归模型中测试临床变量，以预测抗凝不足，抗凝不足定义为术后第8天至第15天出现非治疗性INR≥5天。
共纳入81例患者（男性占56%，年龄62±19岁），接受瓣膜成形术（37%）、机械瓣膜置换术（17%）和生物瓣膜置换术（45%）。从第1天到第7天的华法林规定剂量显著高于第8天到第15天（分别为4.6±3.6和3.0±1.1mg，p<0.001）。总体而言，TTR为6±3天，而INR升高和降低的时间分别占1.3±1.6天和8.0±3.5天。在第7天，只有25%的患者（n = 20）显示出治疗性INR值。41例（51%）患者在术后第8天至第15天出现抗凝不足，多因素分析显示高血压是唯一的独立预测因素（p<0.001）。
尽管进行了密切监测，但在接受华法林治疗的HVS患者术后前两周，仍有一半患者的INR值未达到治疗水平（主要是低于治疗水平）。鉴于许多患者在住院期间无法实现稳定的OAT的高风险，心脏外科医生和心脏病专家都不应错过改善患者教育的机会，并应考虑在出院后直接对接抗凝管理服务。
