Michael Gray Robert, Nagendran Myura, Maruthappu Mahiben
St John's College, University of Oxford, St Giles, Oxford, UK.
Interact Cardiovasc Thorac Surg. 2011 Dec;13(6):642-8. doi: 10.1510/icvts.2011.282319. Epub 2011 Sep 1.
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was: is it safe to stop anticoagulants after successful surgery for atrial fibrillation? Altogether, 177 papers were found using the reported search, of which 14 were selected that represented the best evidence to answer the clinical question. Selection criteria included study relevance, primary outcome, size of study population and length of follow-up. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The weight of evidence, including over 10,000 patient-years of follow-up, supports the discontinuation of warfarin following atrial fibrillation correction procedures as being safe, with an associated annual thromboembolic stroke rate of 0-3.8% off warfarin, in studies where warfarin was stopped at a mean of 3.6 months (range 0-8 months) after the procedure. However, the confidence of this conclusion suffers from a paucity of high-quality randomized controlled trials in the field, with the main body of evidence coming instead from observational non-randomized studies. The stroke rate also varies with the exact procedure performed; pulmonary vein isolation procedures are the most extensively evaluated and carry the lowest stroke rate following warfarin discontinuation (0-0.4% per annum when performed as an isolated procedure). By contrast, left atrial appendage occlusion by insertion of a transcatheter device has an associated annual stroke rate of 0-3.8% off warfarin. Thus, discontinuation of warfarin following such transcatheter procedures cannot be recommended at this time. Concomitant heart surgeries, such as mitral valve repair have been shown to increase the thromboembolic rate both unpredictably and dramatically, and this review thus identifies concomitant mitral valve surgery as a potentially substantial risk factor for late thromboembolic stroke in patients undergoing corrective surgeries for atrial fibrillation. This review finds in favour of warfarin discontinuation in selected patients at three months post-procedure, emphasizing consideration of the patient's individual risk-factor profile as paramount. This recommendation is in line with the 2010 guidelines for the management of atrial fibrillation produced by the European Society of Cardiology.
一篇心胸外科的最佳证据主题文章是根据结构化方案撰写的。所探讨的问题是：房颤成功手术后停用抗凝剂是否安全？通过报告的检索共找到177篇论文，其中14篇被选中，它们代表了回答该临床问题的最佳证据。选择标准包括研究相关性、主要结局、研究人群规模和随访时长。将这些论文的作者、期刊、出版日期和国家、所研究的患者群体、研究类型、相关结局及结果制成表格。包括超过10000患者年随访数据在内的证据权重支持房颤矫正手术后停用华法林是安全的，在术后平均3.6个月（范围0 - 8个月）停用华法林的研究中，停用后每年血栓栓塞性卒中发生率为0 - 3.8%。然而，该结论的可信度因该领域高质量随机对照试验的匮乏而受到影响，主要证据来自观察性非随机研究。卒中发生率也因所实施的确切手术而有所不同；肺静脉隔离术是评估最广泛的，停用华法林后卒中发生率最低（单独实施时每年0 - 0.4%）。相比之下，经导管装置插入封堵左心耳停用华法林后每年卒中发生率为0 - 3.8%。因此，目前不建议在此类经导管手术后停用华法林。诸如二尖瓣修复等同期心脏手术已被证明会不可预测且显著增加血栓栓塞率，本综述因此将同期二尖瓣手术确定为接受房颤矫正手术患者晚期血栓栓塞性卒中的一个潜在重大风险因素。本综述支持在术后三个月对选定患者停用华法林，强调将患者个体风险因素概况的考量置于首位。该建议与欧洲心脏病学会发布的2010年房颤管理指南一致。
