Department of Pharmacy, Kaiser Permanente Colorado, Aurora2Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora.
Department of Pharmacy, Kaiser Permanente Colorado, Aurora3College of Pharmacy, University of Utah, Salt Lake City.
JAMA Intern Med. 2015 Jul;175(7):1163-8. doi: 10.1001/jamainternmed.2015.1843.
The risk of bleeding and recurrent venous thromboembolism (VTE) among patients receiving long-term warfarin sodium therapy for secondary VTE prevention who require temporary interruption of anticoagulant therapy for surgery or invasive diagnostic procedures has not been adequately described.
To describe the rates of clinically relevant bleeding and recurrent VTE among patients in whom warfarin therapy is interrupted for invasive procedures and compare these rates among patients who did and did not receive bridge therapy.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted at Kaiser Permanente Colorado, an integrated health care delivery system. Patients in whom warfarin therapy was interrupted for invasive diagnostic or surgical procedures between January 1, 2006, and March 31, 2012, were identified via queries of administrative data sets. A total of 1812 procedures in 1178 patients met inclusion criteria. Data on outcomes and exposures were collected between June 1, 2005, and April 30, 2012.
Use of bridge therapy vs no bridge therapy during warfarin interruption.
Thirty-day clinically relevant bleeding, recurrent VTE, and all-cause mortality. Outcomes were verified via manual review of medical records.
Among the 1178 patients, the mean (SD) age was 66.1 (12.7) years, 830 procedures (45.8%) were in men, and the most common indication for warfarin therapy was deep vein thrombosis (56.3%). Most patients were considered to be at low risk for VTE recurrence at the time of warfarin interruption (1431 procedures [79.0%]) according to the consensus guidelines of the American College of Chest Physicians. Clinically relevant bleeding within 30 days after the procedure in the bridge therapy and non-bridge therapy groups occurred in 15 patients (2.7%) and 2 patients (0.2%), respectively (hazard ratio, 17.2; 95% CI, 3.9-75.1). There was no significant difference in the rate of recurrent VTE between the bridge and non-bridge therapy groups (0 vs 3; P = .56). No deaths occurred in either group.
Bridge therapy was associated with an increased risk of bleeding during warfarin therapy interruption for invasive procedures in patients receiving treatment for a history of VTE and is likely unnecessary for most of these patients. Further research is needed to identify patient- and procedure-related characteristics associated with a high risk of perioperative VTE recurrence during warfarin therapy interruption.
接受华法林钠长期治疗以预防继发性静脉血栓栓塞症 (VTE) 的患者，在因手术或有创诊断程序而需要暂时中断抗凝治疗时，其出血和复发性静脉血栓栓塞症 (VTE) 的风险尚未得到充分描述。
描述华法林治疗中断期间因有创程序而接受治疗的患者中临床相关出血和复发性 VTE 的发生率，并比较接受桥接治疗和未接受桥接治疗的患者之间的这些发生率。
设计、设置和参与者：这是一项在科罗拉多州 Kaiser Permanente 进行的回顾性队列研究，这是一个综合医疗服务提供系统。通过对行政数据集的查询，确定了 2006 年 1 月 1 日至 2012 年 3 月 31 日期间因有创诊断或手术程序而中断华法林治疗的患者。共有 1178 名患者的 1812 次程序符合纳入标准。2005 年 6 月 1 日至 2012 年 4 月 30 日期间收集了结局和暴露的数据。
桥接治疗与华法林中断期间无桥接治疗。
30 天内临床相关出血、复发性 VTE 和全因死亡率。通过对医疗记录的人工审查来验证结局。
在 1178 名患者中，平均（SD）年龄为 66.1（12.7）岁，830 次手术（45.8%）为男性，最常见的华法林治疗指征是深静脉血栓形成（56.3%）。根据美国胸科医师学会的共识指南，大多数患者在华法林中断时被认为是低复发 VTE 风险（1431 次手术[79.0%]）。桥接治疗组和非桥接治疗组在术后 30 天内发生的 30 天内临床相关出血分别为 15 例（2.7%）和 2 例（0.2%）（风险比，17.2；95%CI，3.9-75.1）。桥接治疗组和非桥接治疗组的复发性 VTE 发生率无显著差异（0 例与 3 例；P=0.56）。两组均无死亡病例。
在接受华法林治疗以预防 VTE 复发的患者中，桥接治疗与华法林治疗中断期间有创程序出血风险增加相关，对于大多数患者来说，桥接治疗可能是不必要的。需要进一步研究以确定与华法林治疗中断期间围手术期 VTE 复发高风险相关的患者和程序特征。
