School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
Postgraduate Program in Adult Health Sciences, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
J Thromb Haemost. 2015 Sep;13(9):1557-67. doi: 10.1111/jth.13047. Epub 2015 Jul 29.
To perform a systematic review and meta-analysis of studies evaluating anticoagulation during the early postoperative period following mechanical heart valve implantation.
Five literature databases were searched to assess the rates of bleeding and thromboembolic events among patients receiving oral anticoagulation (OAC), both with and without bridging anticoagulation therapy with unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH). The studies' results were pooled via a mixed effects meta-analysis. Heterogeneity (I(2) ) and publication bias were both evaluated.
Twenty-three studies including 9534 patients were included. The bleeding rates were 1.8% (95% confidence interval CI 1.0-3.3) in the group receiving OAC, 2.2% (95% CI 0.9-5.3) in the OAC + UFH group, and 5.5% (95% CI 2.9-10.4) in the OAC + LMWH group (P = 0.042). The thromboembolic event rate was 2.1% (95% CI 1.5-2.9) in the group receiving OAC, as compared with 1.1% (95% CI 0.7-1.8) when the bridging therapy groups were combined as follows: OAC + UFH and OAC + LMWH (P = 0.035). Most of the analyses showed moderate heterogeneity and negative test results for publication bias.
Bridging therapy following cardiac valve surgery was associated with a lower thromboembolic event rate, although the difference was small, with considerable overlap of the CIs. Direct comparisons are missing. Bridging therapy with UFH appears to be safe; however, this observation has a risk of bias. Early bridging therapy with LMWH appears to be associated with consistently high bleeding rates across multiple analyses. On the basis of the quality of the included studies, more trials are necessary to establish the clinical relevance of bridging therapy and the safety of LMWH.
系统评价和荟萃分析机械心脏瓣膜植入术后早期接受抗凝治疗的研究。
检索了 5 个文献数据库，评估了接受口服抗凝剂（OAC）治疗的患者的出血和血栓栓塞事件发生率，以及是否同时接受未分级肝素（UFH）或皮下低分子肝素（LMWH）桥接抗凝治疗。通过混合效应荟萃分析对研究结果进行汇总。评估了异质性（I²）和发表偏倚。
纳入了 23 项研究，共 9534 名患者。OAC 组出血率为 1.8%（95%可信区间 CI 1.0-3.3），OAC+UFH 组为 2.2%（95%CI 0.9-5.3），OAC+LMWH 组为 5.5%（95%CI 2.9-10.4）（P=0.042）。OAC 组血栓栓塞事件发生率为 2.1%（95%CI 1.5-2.9），OAC+UFH 和 OAC+LMWH 联合桥接治疗组的发生率为 1.1%（95%CI 0.7-1.8）（P=0.035）。大多数分析显示存在中度异质性，且发表偏倚检验结果为阴性。
心脏瓣膜手术后桥接治疗与较低的血栓栓塞事件发生率相关，尽管差异较小，但置信区间有较大重叠。缺乏直接比较。UFH 桥接治疗似乎是安全的；然而，这一观察结果存在偏倚风险。LMWH 早期桥接治疗在多项分析中均与较高的出血率相关。基于纳入研究的质量，需要更多的试验来确定桥接治疗的临床意义和 LMWH 的安全性。
