心脏瓣膜置换术后华法林抗凝治疗强度的临床观察

Clinical study of the appropriate range of warfarin anticoagulant therapy intensity in patients after heart valve replacement

目的探讨二尖瓣置换术（MVR）和双瓣置换术（DVR）后华法林抗凝治疗国际标准化比值（INR）的适宜范围。方法对1592例我院MVR和DVR术后应用华法林抗凝治疗的患者进行临床随访研究，收集记录患者的入院信息，华法林剂量和INR值等资料，观察出血、血栓栓塞等不良事件发生情况。将入选患者按照瓣膜置换位置不同分为MVR和DVR，然后再将MVR和DVR分为A组（283例）、A1组（229例）（INR=1．4～1．7），B组（299例）、B1组（255例）（INR=1．7—2．0），C组（186例）、c1组（159例）（INR=2．0～2．3），D组（95例）、D1组（86例）（INR=2．3～2．6）进行对比研究。结果出血事件发生率分析：MVR四个不同范围之间差异有统计学意义（x。=20．85，P〈0．01）。A组、B组、C组与D组出血事件发生率比较明显下降，差异均有统计学意义（X。值分别为17．991、13．436、7．186，P均〈0．01）。DVR四个不同范围之间差异有统计学意义（x。=19．067，P〈0．01）。D1组出血事件发生率较其他3组均显著升高且差异有统计学意义（X2值分别为16．736、10．486、7．773，P均〈0．01）。MVR和DVR在INR=1．4—2．3范围内出血事件和血栓栓塞事件发生率比较差异均无统计学意义（P均〉0．05）。结论MVR，DVR在术后抗凝治疗强度方面可以等同，两者控制在INR=1．4—2．3较为合适。

Objective To explore the best range of international normalized ratio for anticoagulation treatment after mitral valve replacement （MVR） and double valve replacement （DVR）. Methods We conducted a follow-up study involving 1592 patients who received the warfarin anticoagulant therapy after MVR or DVR in our hospital. Clinical data was collected including the admission information, the dose of warfarin and the INR level, and the occurrence of bleeding and thrombosis were recorded. The patients were divided into 2 （MVR and DVR） groups in terms of the different valve prostheses, and then each group was assigned to four subgroups according to their INR level （ A ： INR = 1.4 - 1.7 ; B ： INR = 1.7 - 2.0 ; C ： INR = 2. 0 - 2. 3 ; and D ： INR = 2. 3 - 2. 6） to compare the incidence of bleeding and thrombosis among these subgroups. Results The analysis of the incidence of bleeding： In MVR group, the subgroups with different INR levels had significant difference with participants with INR level at D having higher incidence of bleeding than the other 3 groups （Group A：X2 = 17. 991, Group B： ~2 = 13.436, Group C： X2 = 7. 186; P 〈 0. 01 ）. We observed significant difference in DVR groups （X2 = 19. 067,P 〈0. 01 ） with the increased incidence of bleeding of INR level at D compared with the other three groups （Group A：X2 = 16. 736,Group B：X2 = 10. 486,Group C：X2 =7.773;P 〈 0. 01 ）. The analysis of the occurrence of thrombosis; The groups of MVR and DVR had no significant differenceson in the incidences of thrombosis in all the levels of INR （ P 〉 0.05 ）. No significant statistical differences were found on the incidence of bleeding and thrombosis at INR level 1.4 - 2. 3 （ P 〉 0.05 ） ~ Conclusion The present study suggestes that the level of INR at 1.4-2. 3 is appropriate after the anticoagulation therapy in the MVR and DVR groups.