Department of Pharmacy Services, Oregon Health & Science University, Portland, Oregon.
Department of Pharmacy, Stanford Medical Center, Stanford, California.
Clin Cardiol. 2019 Oct;42(10):995-1002. doi: 10.1002/clc.23256. Epub 2019 Sep 4.
Perioperative bridging in atrial fibrillation (AF) is associated with low thromboembolic rates but high bleeding rates. Recent guidance cautions the practice of bridging except in high risk patients. However, the practice of bridging varies widely and little data exist regarding appropriate anticoagulation intensity when using intravenous unfractionated heparin (UFH).
To determine if high intensity UFH infusion regimens are associated with increased bleeding rates compared to low intensity regimens for bridging patients with AF.
We conducted a single center retrospective cohort study of admitted patients with non-valvular AF receiving UFH for ≥24 hours. UFH intensities were chosen at the providers' discretion. The primary endpoint was the rate of bleeding defined by the International Society on Thrombosis and Hemostasis during UFH infusion or within 24 hours of discontinuation. The secondary endpoint was a composite of cardiovascular events, arterial thromboembolism, venous thromboembolism, myocardial infarctions and death during UFH infusion.
A total of 497 patients were included in this analysis. Warfarin was used in 82.1% and direct acting oral anticoagulants in 14.1% of patients. The rate of any bleed was higher among high intensity compared to low intensity UFH regimens (10.5% vs 4.9%, odds ratio = 2.29, 95% confidence interval = 1.07-4.90). Major bleeding was significantly higher among high intensity compared to low intensity UFH regimens. There was no difference in composite thrombotic events or death.
Low intensity UFH infusions, targeting lower anticoagulation targets, were associated with decreased bleeding rates without a signal of increased thromboembolic events in hospitalized AF patients.
心房颤动（AF）围手术期桥接与低血栓栓塞率相关，但出血率较高。最近的指南告诫，除非在高危患者中，否则不应进行桥接治疗。然而，桥接的做法差异很大，并且在使用未分级肝素（UFH）时，关于适当的抗凝强度的数据很少。
确定高强度 UFH 输注方案是否与桥接 AF 患者的出血率增加相关，而不是低强度方案。
我们进行了一项单中心回顾性队列研究，研究对象为接受 UFH 治疗≥24 小时的非瓣膜性 AF 住院患者。UFH 强度由提供者自行选择。主要终点是在 UFH 输注期间或停药后 24 小时内发生的出血率，由国际血栓和止血学会定义。次要终点是 UFH 输注期间的心血管事件、动脉血栓栓塞、静脉血栓栓塞、心肌梗死和死亡的复合终点。
共有 497 名患者纳入本分析。华法林在 82.1%的患者中使用，直接作用口服抗凝剂在 14.1%的患者中使用。与低强度 UFH 方案相比，高强度 UFH 方案的任何出血发生率更高（10.5%比 4.9%，优势比=2.29，95%置信区间=1.07-4.90）。高强度 UFH 方案的大出血发生率明显高于低强度 UFH 方案。复合血栓事件或死亡无差异。
低强度 UFH 输注，靶向较低的抗凝目标，与住院 AF 患者的出血率降低相关，而没有血栓栓塞事件增加的信号。
