Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, Ontario, Canada.
Circulation. 2012 Sep 25;126(13):1630-9. doi: 10.1161/CIRCULATIONAHA.112.105221. Epub 2012 Aug 21.
Periprocedural bridging with unfractionated heparin or low-molecular-weight heparin aims to reduce the risk of thromboembolic events in patients receiving long-term vitamin K antagonists. Optimal periprocedural anticoagulation has not been established.
MEDLINE, EMBASE, and Cochrane databases (2001-2010) were searched for English-language studies including patients receiving heparin bridging during interruption of vitamin K antagonists for elective procedures. Data were independently collected by 2 investigators (κ=0.90). The final review included 34 studies with 1 randomized trial. Thromboembolic events occurred in 73 of 7118 bridged patients (pooled incidence, 0.9%; 95% confidence interval [CI], 0.0.0-3.4) and 32 of 5160 nonbridged patients (pooled incidence, 0.6%; 95% CI, 0.0-1.2). There was no difference in the risk of thromboembolic events in 8 studies comparing bridged and nonbridged groups (odds ratio, 0.80; 95% CI, 0.42-1.54). Bridging was associated with an increased risk of overall bleeding in 13 studies (odds ratio, 5.40; 95% CI, 3.00-9.74) and major bleeding in 5 studies (odds ratio, 3.60; 95% CI, 1.52-8.50) comparing bridged and nonbridged patients. There was no difference in thromboembolic events (odds ratio, 0.30; 95% CI, 0.04-2.09) but an increased risk of overall bleeding (odds ratio, 2.28; 95% CI, 1.27-4.08) with full versus prophylactic/intermediate-dose low-molecular-weight heparin bridging. Low-thromboembolic-risk and/or non-vitamin K antagonist patient groups were used for comparison. Study quality was poor with heterogeneity for some analyses.
Vitamin K antagonist-treated patients receiving periprocedural heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to nonbridged patients. Randomized trials are needed to define the role of periprocedural heparin bridging.
在接受长期维生素 K 拮抗剂治疗的患者中，进行经皮介入操作时使用普通肝素或低分子肝素桥接治疗，旨在降低血栓栓塞事件的风险。但目前尚未确定最佳的围手术期抗凝治疗方案。
检索了 MEDLINE、EMBASE 和 Cochrane 数据库（2001 年至 2010 年），纳入了中断维生素 K 拮抗剂治疗择期手术时使用肝素桥接治疗的患者的研究。由两位研究人员独立采集数据（κ=0.90）。最终的综述纳入了 34 项研究，其中包括 1 项随机试验。在 7118 例接受桥接治疗的患者中，73 例（合并发生率为 0.9%；95%可信区间[CI]，0.0.0-3.4）发生血栓栓塞事件，5160 例未接受桥接治疗的患者中，32 例（合并发生率为 0.6%；95%CI，0.0-1.2）发生血栓栓塞事件。在 8 项比较桥接组和未桥接组的研究中，两组血栓栓塞事件的风险无差异（比值比，0.80；95%CI，0.42-1.54）。在 13 项研究中，桥接治疗与总体出血风险增加相关（比值比，5.40；95%CI，3.00-9.74），在 5 项研究中，桥接治疗与主要出血风险增加相关（比值比，3.60；95%CI，1.52-8.50）。与未桥接治疗患者相比，桥接治疗与血栓栓塞事件（比值比，0.30；95%CI，0.04-2.09）无差异，但总体出血风险增加（比值比，2.28；95%CI，1.27-4.08）。与低分子肝素桥接治疗的低血栓栓塞风险和/或非维生素 K 拮抗剂患者相比，全剂量与预防/中等剂量低分子肝素桥接治疗的患者出血风险增加。
与未桥接治疗的患者相比，接受围手术期肝素桥接治疗的维生素 K 拮抗剂治疗患者似乎有更高的总体出血和主要出血风险，且血栓栓塞事件的风险无差异。需要进行随机试验来明确围手术期肝素桥接治疗的作用。
