PACE：抗凝患者围手术期过渡抗凝指南执行力度不够

长期接受抗凝的患者在植入起搏器时围手术期的管理对医生而言是相当困难的。尤其是对那些具有中高危动脉血栓栓塞（ATE）风险的患者（如风险>4%每年），如机械性瓣膜置换术后、CHADS2高评分的房颤患者。

无过渡抗凝措施的围手术期ATE风险，可用发生事件的年风险指数来评估。如，机械性二尖瓣置换术后的患者，其不使用口服抗凝药物的ATE年风险为17%，也就说7天内发生ATE的风险为0.4%。同样的，CHADS2评分3分以上的房颤患者，不使用口服抗凝药物的ATE年风险为5.9%，估计七天内风险为0.16%。上诉估算方法为线性估计，也就是说，没有考虑围手术风险上升的可能。但已有数据表明外科手术本身会导致高凝状态，导致血栓栓塞风险一过性升高。

临床医生处理围手术期血栓栓塞的对策是给中高危患者使用过渡抗凝治疗。在过渡方案中，术前3~5天停用口服抗凝药物，代之以静脉使用的普通肝素或使用低分子肝素，后者更为常见。术后，患者继续使用普通肝素或低分子肝素，知道口服抗凝药达到治疗水平。

多项指南都推荐了这种方案，都建议应在患者的血栓栓塞风险和因手术而升高的出血风险之间做出权衡，都提及机械性瓣膜置换术后尤其是二尖瓣置换术后患者、合并其他危险因素的房颤患者、近期（3个月内）静脉血栓患者的血栓栓塞风险最高。临床上最详细且接受程度最高的指南是ACCP2008年的指南，其中推荐中高危动静脉血栓患者应使用过渡抗凝。

加拿大渥太华大学的MARK J. PERRIN，希望通过研究，探讨现实医疗工作中，此过渡抗凝治疗方案在多大程度上被临床医生接受、执行。

MARK J. PERRIN等检视了预先设定的14个月期间内所有接受抗凝治疗且行起搏器植入的患者。这些患者根据临床资料集ACCP2008年指南，分为中高危组和低危组。随后将两组患者围手术期抗凝治疗与指南推荐的方案比较，并评估两组患者围手术期出血率和血栓栓塞发生率。

研究小组一共回顾了129名患者的临床资料。其中62名（48%）为中高危患者，67名（52%）为低危患者。在中高危组中有47名（76%）接受了围手术期抗凝治疗，仅有25名（40%）术前术后都应用过渡抗凝或未中断使用华法林。在低危组中，22名（33%）接受了围手术期抗凝治疗。起搏器囊袋血中或围手术期出血，共有10例（8%）其中4例发生在不恰当地接受了过渡抗凝治疗的低危组患者中。围手术期未发生血栓栓塞事件。

基于这个小规模的研究，MARK J. PERRIN等得出结论，过渡抗凝治疗明显地执行的不够充分，尤其是术后阶段，在中高危组患者中。与此相反，对低危组患者，却过度适用了过渡抗凝治疗并出现了出血并发症。这一结论提示，临床医生在植入起搏器时应更多的遵从目前的专家指南，适用过渡抗凝治疗。

DOI: 10.1111/j.1540-8159.2012.03516.x
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Anticoagulation Bridging Around Device Surgery: Compliance with Guidelines

MARK J. PERRIN M.B.B.S., Ph.D.1, BRIAN Z. VEZI M.D.1, ANDREW C. HA M.D.2, ARIEH KEREN M.D.1, PABLO B. NERY M.D.1, DAVID H. BIRNIE M.B., Ch.B., M.D.1

Background:Current guidelines recommend bridging anticoagulation in patients undergoing cardiac rhythm device surgery with a “moderate to high risk” of thromboembolism. Patients at “low risk” are advised to stop oral anticoagulation without bridging to the procedure. This study examines real world adherence to accepted guidelines and the clinical sequelae of nonadherence. Methods:We performed a review of all patients undergoing device surgery receiving chronic anticoagulation over a prespecified time period of 14 months. Patients were classified per American College of Chest Physician guidelines as “moderate/high risk” or “low risk” of thromboembolism. We then compared perioperative management of anticoagulation to guideline recommendations and assessed the rate of perioperative bleeding and thromboembolism. Results:One hundred and twenty-nine patients were included in this study. Sixty-two (48%) were classified as “moderate/high risk” and 67 (52%) “low risk.” In the “moderate/high risk” group 47/62 (76%) received perioperative anticoagulation but only 25/62 (40%) were bridged both pre- and postprocedure or maintained on uninterrupted warfarin. In the “low risk” group, 22/67 (33%) received bridging therapy. Device pocket hematoma or perioperative bleeding occurred in 10/129 (8%) with 4/10 receiving inappropriate bridging for a calculated low risk of thromboembolism. There were no perioperative thromboembolisms. Conclusions:Our study identified significant underutilization of bridging, particularly in the postoperative period, in patients at “moderate/high risk” of thromboembolism. Conversely, bridging was overused in “low risk” patients and associated with bleeding complications. Physicians should be urged to follow current expert guidelines in regard to bridging anticoagulation for cardiac rhythm device surgery.