长期服用华法林冠心病患者冠状动脉介入治疗围术期抗栓策略的探讨

Perioperative antithrombotic strategy in coronary intervention therapy for the patients with coronary heart disease treated with long-term warfarin anticoagulation

目的探讨长期服用华法林冠心病患者接受经皮冠状动脉介入治疗(PCI)围术期的抗栓策略,评价其安全性及近期疗效。方法分析2002年1月-2007年12月在沈阳军区总医院住院的76例长期服用华法林不稳定型心绞痛患者行PCI的临床资料。服用华法林的原因为:心脏金属瓣膜置换术51例(67.1%),半年内的肺栓塞6例(7.9%),永久性房颤伴血栓高危因素19例(25%)。PCI术前停华法林用常规剂量低分子肝素(LMWH)替代,当国际标准化比率(INR)≤1.3时行PCI。术后在应用小剂量阿司匹林(ASA)100mg/d及氯吡格雷75mg/d的基础上联用LMWH,并恢复华法林,INR达到1.8以上停用LMWH,调整华法林用量使INR维持在1.8～2.3之间,1个月后停用氯吡格雷,继续用ASA(75～100mg/d),华法林恢复至支架术前剂量。观察住院期间缺血事件、主要不良心脏事件(MACE)、支架内亚急性血栓形成(SAT)及出血的发生率。结果出血事件5.3%(4/76),其中次要出血1例1.3%(1/76),MACE发生率1.3%(1/76),未因调整抗栓治疗方案而发生主要出血及SAT。结论长期服用华法林的冠心病患者接受PCI术前用LMWH替代华法林,术后短时间内联用小剂量ASA、氯吡格雷、LMWH及华法林,根据INR精确调整华法林剂量并适时停用LMWH,这一特殊抗栓策略安全、有效,且可行性较好。

Objective To explore the perioperative antithrombotic strategy in percutaneous coronary intervention（PCI）for the patients with coronary heart disease（CHD）who were treated with long-term warfarin anticoagulation,and to evaluate the safety of the strategy and short-term efficacy.Methods The clinical data of 76 patients were analyzed,who underwent coronary stenting while treated with long-term warfarin anticoagulation.All of them had unstable angina.The reasons of requiring warfarin anticoagulation were cardiac valve replacement [51（67.1%）],pulmonary embolism within half a year [6（7.9%）],and sustained atrial fibrillation at high risk of stroke [19（25.0%）].Warfarin was withdrawn and low molecular weight heparin（LMWH）was administered as alternative anti-thrombus drugs before PCI.PCI was performed when international normalized ratio（INR）went less than or equal to 1.3.LMWH was administered combined with low dose aspirin（100mg/d）and clopidogrel（75mg/d）post PCI,while warfarin was resumed too.When INR arrived at 1.8,LMWH was withdrawn.Warfarin was administered in a dose adjusted to achieve the target INR of 1.8 to 2.3.Clopidogrel was withdrawn 1 month later.Aspirin（75-100mg/d）was continued,and then warfarin was resumed to the dose before PCI.The data of the incidence of ischemic events,major adverse cardiac events（MACE）,subacute instent thrombus（SAT）,and hemorrhage events during hospital period were analyzed.Results The incidence of hemorrhage events was 5.3%（4/76）,one of them was secondary hemorrhage events.The rate of MACE was 1.3%（1/76）.No main hemorrhage events and SAT occurred during hospitalization related to regulating antithrombotic strategy.Conclusions As alternatives of warfarin,LMWH is taken before PCI,and then the low dose of aspirin,clopidogrel,LMWH and warfarin are admitted in a short period after PCI,the dosage of warfarin should be accurately adjusted according INR post PCI,and then the LMWH is taken out of service timely,such a strategy is safe and efficient in peri-percutaneous coronary intervention for the patients with CHD who were treated with maintaining warfarin anticoagulation.