de Bono Joseph, Nazir Sheraz, Ruparelia Neil, Bashir Yaver, Betts Tim, Rajappan Kim
Department of Cardiology, John Radcliffe Hospital, Oxford, UK.
Pacing Clin Electrophysiol. 2010 Apr;33(4):389-93. doi: 10.1111/j.1540-8159.2009.02683.x. Epub 2010 Jan 27.
Increasing numbers of patients taking oral anticoagulation are presenting for device implantation. Cessation of anticoagulation in the perioperative period may expose patients to increased risk of thromboembolic events, while continuing anticoagulation may increase the risk of bleeding. There are few guidelines or randomized controlled trials to guide perioperative management.
We carried out a questionnaire-based study of all cardiologists implanting devices in the United Kingdom to establish if there was consensus on management of anticoagulation in patients undergoing pacemaker implantation.
There is significant variation in management of these patients. Eighty-nine percent of doctors stop oral anticoagulation a mean 3.7 days prior to pacemaker implantation in patients with a mechanical mitral valve, with 94% using heparin to provide preoperative anticoagulation: 58% unfractionated heparin, 40% low molecular weight heparin. The maximum accepted international normalized ratio for implantation ranged from 1.4 to 3 (median 1.8). Postoperatively, 86% restart heparin after a mean 8.5 hours. Only 11% continue oral anticoagulation throughout the implantation period. There is a hierarchy of perceived embolic risk with doctors using progressively less anticoagulation in patients with prosthetic aortic valve, high-risk, and low-risk atrial fibrillation. In contrast, only 7% of implanters stop theinopyridines prior to device implantation in patients with a 2-month-old drug eluting stent.
Perioperative anticoagulation management of patients undergoing device procedures is currently performed with little consensus. This emphasizes the need for careful national and international audit of periprocedural anticoagulation management and its associated complications with a view to developing international consensus guidelines. (PACE 2010; 389-393).
越来越多正在接受口服抗凝治疗的患者需要进行器械植入。围手术期停用抗凝药物可能会使患者面临血栓栓塞事件风险增加的问题，而继续抗凝则可能增加出血风险。几乎没有指南或随机对照试验可用于指导围手术期管理。
我们对英国所有植入器械的心脏病专家进行了一项基于问卷调查的研究，以确定在起搏器植入患者的抗凝管理方面是否存在共识。
这些患者的管理存在显著差异。在植入机械二尖瓣的患者中，89%的医生在起搏器植入前平均3.7天停用口服抗凝药物，94%的医生使用肝素进行术前抗凝：58%使用普通肝素，40%使用低分子肝素。植入时接受的国际标准化比值最大值范围为1.4至3（中位数为1.8）。术后，86%的医生在平均8.5小时后重新使用肝素。只有11%的医生在整个植入期间继续使用口服抗凝药物。对于人工主动脉瓣、高危和低危房颤患者，医生认为的栓塞风险存在等级差异，使用的抗凝药物逐渐减少。相比之下，在植入2个月的药物洗脱支架的患者中，只有7%的植入者在器械植入前停用噻氯匹定。
目前，器械操作患者围手术期抗凝管理的实施几乎没有达成共识。这凸显了对围手术期抗凝管理及其相关并发症进行仔细的国内和国际审核的必要性，以期制定国际共识指南。（《PACE》2010年；389 - 393页）
