Duke Clinical Research Institute, Durham, North Carolina, USA.
J Am Coll Cardiol. 2012 Sep 11;60(11):971-7. doi: 10.1016/j.jacc.2012.05.029. Epub 2012 Aug 22.
The aim of this study was to evaluate the risks and benefits of short-term anticoagulation in patients receiving aortic valve bioprostheses.
Patients receiving aortic valve bioprostheses have an elevated early risk of thromboembolic events; however, the risks and benefits of short-term anticoagulation have been debated with limited evidence.
Our cohort consisted of 25,656 patients ≥65 years of age receiving aortic valve bioprostheses at 797 hospitals within the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2004 to 2006). The associated 3-month incidences of death or readmission for embolic (cerebrovascular accident, transient ischemic attack, and noncerebral arterial thromboembolism) or bleeding events were compared across discharge anticoagulation strategies with propensity methods.
In this cohort (median age, 77 years), the 3 most common discharge anticoagulation strategies included: aspirin-only (49%), warfarin-only (12%), and warfarin plus aspirin (23%). Among those receiving aspirin-only, 3-month adverse events were low (death, 3.0%; embolic events, 1.0%; bleeding events, 1.0%). Relative to aspirin-only, those treated with warfarin plus aspirin had a lower adjusted risk of death (relative risk [RR]: 0.80, 95% confidence interval [CI]: 0.66 to 0.96) and embolic event (RR: 0.52, 95% CI: 0.35 to 0.76) but a higher risk of bleeding (RR: 2.80, 95% CI: 2.18 to 3.60). Relative to aspirin-only, warfarin-only patients had a similar risk of death (RR: 1.01, 95% CI: 0.80 to 1.27), embolic events (RR: 0.95, 95% CI: 0.61 to 1.47), and bleeding (RR: 1.23, 95% CI: 0.85 to 1.79). These results were generally consistent across patient subgroups.
Death and embolic events were relatively rare in the first 3 months after bioprosthetic aortic valve replacement. Compared with aspirin-only, aspirin plus warfarin was associated with a reduced risk of death and embolic events, but at the cost of an increased bleeding risk.
本研究旨在评估主动脉瓣生物瓣置换术后短期抗凝的风险和获益。
主动脉瓣生物瓣置换术后患者早期发生血栓栓塞事件的风险较高；然而，短期抗凝的风险和获益一直存在争议，且证据有限。
我们的队列包括 797 家医院 25656 名年龄≥65 岁的主动脉瓣生物瓣置换患者（2004 年至 2006 年），来自胸外科医师学会成人心脏手术数据库。采用倾向性评分方法比较出院时抗凝策略与 3 个月内死亡或因栓塞（脑卒、短暂性脑缺血发作和非脑动脉血栓栓塞）或出血事件再入院的相关发生率。
在本队列（中位年龄 77 岁）中，最常见的 3 种出院抗凝策略包括：仅阿司匹林（49%）、仅华法林（12%）和华法林加阿司匹林（23%）。仅接受阿司匹林治疗的患者，3 个月不良事件发生率较低（死亡 3.0%、栓塞事件 1.0%、出血事件 1.0%）。与仅阿司匹林治疗相比，华法林加阿司匹林治疗的患者死亡风险（相对风险 [RR]：0.80，95%置信区间 [CI]：0.66 至 0.96）和栓塞事件风险（RR：0.52，95% CI：0.35 至 0.76）较低，但出血风险较高（RR：2.80，95% CI：2.18 至 3.60）。与仅阿司匹林治疗相比，仅华法林治疗的患者死亡风险（RR：1.01，95% CI：0.80 至 1.27）、栓塞事件风险（RR：0.95，95% CI：0.61 至 1.47）和出血风险（RR：1.23，95% CI：0.85 至 1.79）相似。这些结果在各患者亚组中基本一致。
生物瓣主动脉瓣置换术后 3 个月内死亡和栓塞事件相对少见。与仅阿司匹林治疗相比，阿司匹林加华法林治疗可降低死亡和栓塞事件风险，但出血风险增加。
