University of Western Ontario, London, Ontario, Canada, Hamilton Health Sciences Center, Hamilton, Ontario, Canada.
Heart Rhythm. 2009 Sep;6(9):1276-9. doi: 10.1016/j.hrthm.2009.05.027. Epub 2009 Jun 6.
In patients undergoing cardiac rhythm device surgery, it is common practice to discontinue oral anticoagulation and to perform heparin bridging in order to reduce the risk of bleeding and minimize the risk of thromboembolic events.
The purpose of this study was to determine the perioperative anticoagulation strategies currently in use.
A survey presented four clinical scenarios of patients on oral anticoagulation undergoing cardiac rhythm device surgery. The scenarios represented a gradient of perceived thromboembolic risk based on the presence of atrial fibrillation, a mechanical heart valve, previous stroke, and the remainder of the CHADS(2) risk factors (congestive heart failure, hypertension, age >75 years, diabetes, previous stroke or transient ischemic attack). Respondents were offered six options that included discontinuing oral anticoagulation without heparin, three different heparin bridging protocols, and ongoing oral anticoagulation with reduced or therapeutic dose warfarin.
Based on responses from 38 (61%) of 62 electrophysiologists surveyed across Canada, 83% of respondents held warfarin without bridging in a low-risk, 78-year-old patient with atrial fibrillation (CHADS(2) score 1). In three higher-risk patient scenarios, 67% to 100% of respondents chose heparin bridging or ongoing warfarin; 38% to 72% of respondents chose heparin bridging, with 23% to 36% choosing variable use of ongoing warfarin. In all three cases where respondents indicated that they would bridge, each of the three heparin regimens was chosen by at least 20% of respondents.
There is a wide range of approaches to perioperative management in patients on oral anticoagulation undergoing cardiac rhythm device surgery. Clinical equipoise is evident and supports the need for comparative studies.
在接受心脏节律装置手术的患者中，通常会停止口服抗凝治疗并进行肝素桥接，以降低出血风险并最大程度地减少血栓栓塞事件的风险。
本研究旨在确定目前正在使用的围手术期抗凝策略。
一项调查提出了四种正在接受口服抗凝治疗的心脏节律装置手术患者的临床情况。这些情况代表了基于心房颤动、机械心脏瓣膜、既往中风和剩余 CHADS（2）危险因素（充血性心力衰竭、高血压、年龄 >75 岁、糖尿病、既往中风或短暂性脑缺血发作）的感知血栓栓塞风险梯度。受访者提供了六种选择，包括停止口服抗凝治疗而不进行肝素桥接、三种不同的肝素桥接方案以及继续使用低剂量或治疗剂量华法林进行口服抗凝治疗。
根据对加拿大各地 62 名电生理学家中的 38 名（61%）进行的调查的回复，83%的受访者在低风险（CHADS（2）评分 1）、78 岁患有心房颤动的患者中选择不进行肝素桥接（华法林）。在三个风险较高的患者情况下，67%至 100%的受访者选择肝素桥接或继续使用华法林；38%至 72%的受访者选择肝素桥接，23%至 36%的受访者选择继续使用可变剂量的华法林。在所有三个受访者表示他们将进行桥接的情况下，每种肝素方案都至少有 20%的受访者选择。
在接受口服抗凝治疗的心脏节律装置手术患者中，围手术期管理方法多种多样。临床平衡显而易见，支持需要进行比较研究。
