Chandra Dinesh, Gupta Anubhav, Grover Vijay, Kumar Gupta Vijay
Department of Cardiothoracic and Vascular Surgery, PGIMER and Dr RML Hospital, New Delhi, India.
Interact Cardiovasc Thorac Surg. 2013 Apr;16(4):520-3. doi: 10.1093/icvts/ivs545. Epub 2013 Jan 3.
A best evidence topic in cardiac surgery was written according to the structured protocol. The question addressed was about the best time to restart anticoagulation in patients with intracranial bleed with a prosthetic valve in situ. This difficult clinical decision has to balance the risk of thromboembolism during the period that the anticoagulation was reversed and later withheld vs the risk of haematoma expansion or rebleed if the anticoagulation was started early. Altogether, more than 80 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. There were two prospective studies and eight retrospective studies. There were no randomized controlled trials on this topic. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Seven studies reported the strategy of reversal of anticoagulation with vitamin K, fresh frozen plasma or prothrombin concentrate. The emphasis was on prompt initial reversal of anticoagulation; however, the best agent for reversal was not defined. Four studies dealt exclusively with intracranial bleed in patients with prosthetic valve in situ. The remaining six studies on intracranial bleed had only a subset of patients with a prosthetic valve in situ. The anticoagulation was restarted with heparin and later switched to oral anticoagulant. Thromboembolic events during the period of reversal and cessation of anticoagulants were low (5%) as was the incidence of rebleed or haematoma expansion (0.5%). We conclude that anticoagulation can safely be withheld for a short period, up to 7-14 days in a patient with intracranial bleed with a very low probability of thromboembolic phenomenon. In patients with prosthetic valves, in situ anticoagulation in the form of heparin can safely be restarted as early as 3 days and switched to oral anticoagulation in the form of warfarin at 7 days without major concerns of bleeding.
根据结构化方案撰写了一篇心脏外科领域的最佳证据主题文章。所探讨的问题是，对于颅内出血且原位植入人工瓣膜的患者，重新开始抗凝治疗的最佳时机是什么。这一艰难的临床决策必须在抗凝治疗被逆转及随后停用期间的血栓栓塞风险与过早开始抗凝治疗导致血肿扩大或再次出血的风险之间进行权衡。通过报告的检索方式，共找到80多篇论文，其中10篇代表了回答该临床问题的最佳证据。有两项前瞻性研究和八项回顾性研究。关于这个主题没有随机对照试验。这些论文的作者、期刊、发表日期和国家、所研究的患者群体、研究类型、相关结局和结果都列成了表格。七项研究报告了使用维生素K、新鲜冰冻血浆或凝血酶原浓缩物逆转抗凝的策略。重点是迅速进行抗凝的初始逆转；然而，逆转的最佳药物尚未确定。四项研究专门针对原位植入人工瓣膜患者的颅内出血情况。其余六项关于颅内出血的研究中，只有一部分患者原位植入了人工瓣膜。抗凝治疗先以肝素重新开始，随后改为口服抗凝药。抗凝逆转和停用期间的血栓栓塞事件发生率较低（5%），再次出血或血肿扩大的发生率也较低（0.5%）。我们得出结论，对于颅内出血且血栓栓塞现象发生概率极低的患者，抗凝治疗可以安全地停用短时间，最长可达7至14天。对于植入人工瓣膜的患者，肝素形式的原位抗凝治疗最早可在3天安全地重新开始，并在7天转换为华法林形式的口服抗凝治疗，而无需过多担心出血问题。
