Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
Heart Rhythm. 2012 Mar;9(3):361-7. doi: 10.1016/j.hrthm.2011.10.010. Epub 2011 Oct 12.
Perioperative management of oral anticoagulation (OAC) in patients receiving pacemakers or implantable cardioverter-defibrillators remains an issue of concern.
We sought to evaluate the safety and the effect on the hospital length of stay of a new standardized protocol for perioperative management of OAC in this setting.
The new standardized protocol classified patients according to a renewed evaluation of their thromboembolic (TE) risk. Briefly, patients were considered at moderate-to-high TE risk if they had a mechanical valvular prostheses irrespective of type and location or atrial fibrillation associated with a CHADS(2)score of ≥2, mitral stenosis or previous stroke, and underwent device implantation without stopping OAC (OAC continued, n = 129). Complete interruption of OAC before surgery was performed in low-TE-risk patients (OAC interrupted, n = 82). A retrospective cohort of patients managed with a classic heparin-bridging strategy served as a control group, with 62 patients considered at moderate-to-high TE risk according to previous guidelines (receiving pre- and postoperative low-molecular-weight heparin) and 146 considered at low TE risk (receiving only low doses of postoperative low-molecular-weight heparin).
TE events were comparable between the 2 strategies. Patients entering the new standardized protocol had significantly lower rates of pocket hematoma (2.3% for OAC continued vs 17.7% for moderate-to-high TE risk bridging controls, P = .0001, and 0% for OAC interrupted vs 13% for low-TE-risk bridging controls, P <.0001) and shorter hospital stays. A mean of 3.34 hospitalization days per patient were saved with the new standardized protocol, with an estimated cost savings of €850.83 per patient.
Implantation of the new standardized protocol resulted in a significant reduction in bleeding complications and hospital stays, with adequate protection against TE events and significant cost savings.
在接受起搏器或植入式心脏复律除颤器的患者中，围手术期抗凝（OAC）的管理仍然是一个令人关注的问题。
我们旨在评估在这种情况下，一种新的 OAC 围手术期管理标准化方案的安全性和对住院时间的影响。
新的标准化方案根据患者血栓栓塞（TE）风险的重新评估对患者进行分类。简而言之，如果患者有机械瓣假体，无论类型和位置如何，或伴有 CHADS2 评分≥2 的心房颤动、二尖瓣狭窄或既往卒中，且在不停用 OAC 的情况下进行器械植入（OAC 继续，n=129），则认为患者处于中高危 TE 风险。低 TE 风险患者（OAC 中断，n=82）在手术前完全中断 OAC。一组接受经典肝素桥接策略治疗的患者作为对照组，其中 62 例患者根据先前的指南被认为处于中高危 TE 风险（接受术前和术后低分子量肝素），146 例患者被认为处于低 TE 风险（仅接受低剂量术后低分子量肝素）。
两种策略的 TE 事件发生率相当。新标准化方案组的患者血肿发生率明显降低（OAC 继续组为 2.3%，中高危 TE 风险桥接对照组为 17.7%，P=0.0001；OAC 中断组为 0%，低 TE 风险桥接对照组为 13%，P<0.0001），住院时间也更短。新标准化方案平均可为每位患者节省 3.34 天的住院时间，估计每位患者可节省 850.83 欧元的费用。
实施新的标准化方案可显著减少出血并发症和住院时间，同时充分保护患者免受 TE 事件的影响，并显著节省成本。
