心脏瓣膜置换术后华法林抗凝强度的探讨

Anticoagulation intensity with warfarin for patients after heart valve replacement

目的 通过对心脏瓣膜置换术后华法林抗凝治疗的分析,探讨华法林最适抗凝强度.方法 回顾性分析265例心脏瓣膜置换术后患者华法林抗凝治疗、给药方法及国际标准化比值（INR）监测情况.根据瓣膜置换位置的不同,分为主动脉瓣置换术（AVR）组（37例）、二尖瓣置换术（MVR）组（165例）、双瓣膜置换术（DVR）组（63例）,各组再按照不同的抗凝强度,分为INR 1.5～2.0、INR 2.1～ 2.5共2个亚组,对比分析出血及血栓栓塞发生情况.结果 随访患者265例,随访时间4个月至6年.华法林剂量0.625 ～ 7.500（2.5±1.4） mg/d,发生抗凝不良事件23例,其中出血18例（6.79％,18/265）,明显高于血栓栓塞5例（1.89％,5/265）,差异有统计学意义（P＜0.05）.4例出现偏瘫后遗症,死亡2例.AVR组、MVR组、DVR组患者INR 1.5 ～ 2.0出血发生率比INR 2.1 ～ 2.5明显降低[0（0/20）比1/17、3.57％（3/84）比11.11％（9/81）、2.70％ （1/37）比15.38％（4/26）],且差异有统计学意义（P＜0.05）;AVR组、MVR组、DVR组患者INR 1.5 ～ 2.0、2.1～2.5血栓栓塞发生率比较差异均无统计学意义（P＞0.05）.结论 心脏瓣膜置换术后华法林抗凝过程中,宜选择INR 1.5 ～ 2.0低强度抗凝治疗,AVR的INR控制在1.5 ～ 1.8,MVR或DVR的INR控制在1.8～ 2.0,根据不同病情,制定个体化抗凝治疗方案。

Objective To analyze warfarin anticoagulation therapy for patients after heart valve replacement,and to explore an optimal intensity of warfarin anticoagulation.Methods The administration method,international normalized ratio （INR） monitoring of 265 patients who received warfarin anticoagulation therapy after heart valve replacement were analyzed retrospectively.The patients were divided into three groups according to different valve prostheses：aortic valve replacement （AVR） group （37 cases）,mitral valve replacement （MVR） group （165 cases） and double valve replacement （DVR） group （63 cases）.Each group was divided into two subgroups according to their INR levels （INR 1.5-2.0,INR 2.1-2.5）.The occurrence of bleeding and thromboembolic events in these subgroups were compared.Results A total of 265 cases were visited,and followed up for 4 months to 6 years.The dose of warfarin was 0.625-7.500 （2.5 ± 1.4） mg/d.The incidence of anticoagulation adverse events was 23 cases.The incidence of bleeding events was 6.79% （18/265）,which was higher than that of thromboembolic events （1.89%,5/265）,and there was significant difference （P 〈 0.05）.Four cases of the hemiplegia sequelae occurred and 2 cases died.The incidence of bleeing events in patients with INR1.5-2.0 in AVR group,MVR group and DVR group were 0 （0/20）,3.57% （3/84）,2.70% （1/37）,in patients with INR 2.1-2.5 were 1/17,11.11% （9/81）,15.38% （4/26）,and there were significant differences （P 〈 0.05）.There were no significant differences in the incidence of thromboembolic events between INR 1.5-2.0 and INR 2.1-2.5 in AVR group,MVR group and DVR group （P 〉 0.05）.Conclusions After heart valve replacement,the anticoagulation therapy with warfarin is effective and safe to maintain the low intensity anticoagulation （INR1.5-2.0）.AVR and MVR/DVR may benefit from a treatment strategy with levels ranging from 1.5-1.8 and 1.8-2.0,and the anticoagulation therapy of individuation should be formulated according to different conditions.