对接受低分子量肝素治疗的机械人工瓣膜妊娠患者进行抗Xa监测：峰值还是谷值水平？
Monitoring of anti-Xa in pregnant patients with mechanical prosthetic valves receiving low-molecular-weight heparin: peak or trough levels?
作者信息
Goland Sorel, Schwartzenberg Shmuel, Fan John, Kozak Natasha, Khatri Nudrat, Elkayam Uri
机构信息
Heart Institute, Kaplan Medical Center, Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel.
Department of Medicine, Division of Cardiovascular Disease, University of Southern California, Los Angeles, CA, USA Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA.
出版信息
J Cardiovasc Pharmacol Ther. 2014 Sep;19(5):451-6. doi: 10.1177/1074248414524302. Epub 2014 Mar 6.
OBJECTIVES
We hypothesized that the guideline-recommended peak anti-Xa levels for pregnant women with mechanical prosthetic heart valves (MPHVs) receiving adjusted dose low-molecular-weight heparin (LMWH) are associated with subtherapeutic trough levels and consequently with an inadequate level of anticoagulation.
BACKGROUND
Low-molecular-weight heparin is often used for anticoagulation in pregnant women including those with MPHV. American College of Cardiology/American Heart Association guidelines recommend monitoring of plasma anti-Xa factor peak levels and adjustment of the dose to achieve peak levels of 0.7 to 1.2 U/mL. In spite of these recommendations, cases of valve thrombosis during pregnancy continue to occur.
METHODS AND RESULTS
We studied 30 pregnant patients receiving anticoagulation for various indications with adjusted dose LMWH given subcutaneously twice a day which had both trough and peak anti-Xa levels throughout pregnancy for a total of 187 paired determinations. The recommended peak anti-Xa levels (0.7-1.2 U/mL) were obtained in 123 (66%) of the measurements but in 80% of them, the trough levels were found to be subtherapeutic (<0.6 U/mL). Subtherapeutic trough levels were found in 8 (73%) of the 11 measurements with peak levels of 0.7 to 0.79 U/mL, 17 (74%) of the 23 of 0.8 to 0.89 U/mL, 21 (72%) of the 29 of 0.9 to 0.99 U/mL, and 28 (44%) of the 63 of 1.0 to 1.2 U/mL. There were 42 measurements with peak anti-Xa levels >1.2 U/mL and even in these cases, 13 (31%) of the trough levels were found to be subtherapeutic.
CONCLUSIONS
Anticoagulation with adjusted dose LMWH aimed to achieve guideline-recommended peak levels of anti-Xa for patients with MPHVs is commonly associated with subtherapeutic trough levels. Routine measurement of trough anti-Xa levels is therefore advisable in women with MPHV treated with LMWH during pregnancy to assure adequate level of anticoagulation.
目的
我们推测，对于接受调整剂量低分子肝素（LMWH）治疗的机械人工心脏瓣膜（MPHV）孕妇，指南推荐的抗Xa峰值水平与治疗不足的谷值水平相关，因此与抗凝水平不足有关。
背景
低分子肝素常用于包括MPHV孕妇在内的孕妇抗凝治疗。美国心脏病学会/美国心脏协会指南建议监测血浆抗Xa因子峰值水平，并调整剂量以达到0.7至1.2 U/mL的峰值水平。尽管有这些建议，但孕期瓣膜血栓形成的病例仍继续发生。
方法和结果
我们研究了30例因各种适应症接受抗凝治疗的孕妇，她们每天皮下注射两次调整剂量的LMWH，在整个孕期均有抗Xa谷值和峰值水平，共进行了187次配对测定。123次（66%）测量获得了推荐的抗Xa峰值水平（0.7 - 1.2 U/mL），但其中80%的谷值水平被发现低于治疗水平（<0.6 U/mL）。在11次峰值水平为0.7至0.79 U/mL的测量中，有8次（73%）谷值水平低于治疗水平；在23次峰值水平为0.8至0.89 U/mL的测量中，有17次（74%）谷值水平低于治疗水平；在29次峰值水平为0.9至0.99 U/mL的测量中，有21次（72%）谷值水平低于治疗水平；在63次峰值水平为1.0至1.2 U/mL的测量中，有28次（44%）谷值水平低于治疗水平。有42次测量的抗Xa峰值水平>1.2 U/mL，即使在这些情况下，仍有13次（31%）谷值水平低于治疗水平。
结论
对于MPHV患者，旨在达到指南推荐的抗Xa峰值水平的调整剂量LMWH抗凝治疗通常与治疗不足的谷值水平相关。因此，对于孕期接受LMWH治疗的MPHV女性，建议常规测量抗Xa谷值水平，以确保足够的抗凝水平。
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