急诊科华法林相关致命性出血114例分析

Analysis of 114 cases of Warfarin-related major bleeding in Emergency Department

目的调查综合医院急诊科华法林相关致命性出血患者抗凝病因、出血易感因素和临床特点。方法收集温州医科大学附属第一医院急诊科抢救室2017年1月至2020年2月期间收治的华法林相关致命性出血患者,用描述性研究方法分析其抗凝病因、出血易感因素和临床特点。根据出血时国际标准化比值(international normalized ratio,INR),分为INR超范围组和INR未超范围组,采用卡方检验、t检验和Wilcoxon秩和检验对比INR超范围组和非超范围组各项指标的差异。Wilcoxon秩和检验和t检验用于消化道出血和脑出血特点分析。结果共纳入114例华法林相关致命性出血患者。①华法林相关致命性出血分别占急救病例的0.36%(114/32040)、服用华法林病例的9.84%(114/1158)。②抗凝病因:与心房颤动(atrial fibrillation,AF)相关77例(67.5%),与心瓣膜置换术后相关32例(28.1%)。③出血易感因素:HAS-BLED评分4.0(3.0,5.0)分,既往使用药物史84例(73.7%),年龄>65岁77例(67.5%),不定期监测INR65例(57.0%),近期增加剂量29例(25.4%)。④出血部位:消化道出血40例(35.1%),血红蛋白(hemoglobin,Hb)最低,HAS-BLED评分最高;脑出血21例(18.4%),凝血酶原时间(prothrombin time,PT)最短,INR最低,Hb最高,HAS-BLED评分最低。⑤临床预后:死亡(或病危放弃治疗)12例(10.5%),其中脑出血6例、消化道出血5例、咯血1例。⑥INR超范围组(n=86)与INR未超范围组(n=28)比较,在既往抗血小板治疗、近期增加剂量、HAS-BLED评分和出血部位上差异有统计学意义(均P<0.05)。结论在华法林相关致命性出血患者中,AF和心瓣膜置换术后是华法林抗凝的主要原因,INR超范围与既往抗血小板治疗、近期增加剂量和HAS-BLED评分高相关。消化道出血最常见,该组患者Hb最低、HAS-BLED评分最高;脑出血次之,该组患者PT最短、INR最低、Hb最高。华法林服用致相关致命性出血的发生率和病死率均较高。

Objetive To investigate the anticongulant causes,hemorrhagic susecpibility factors and elinical characteristics of patients with warfarin related major bleeding in the emergency department of a general hospital.Methods In a registry study from January 2017 to February 2020,114 eases of warfarin-related major bleeding patients admitted to Department of Emergeney Medicine,the First Afiliated Hospital of Wenzhou Medical University were enrolled The descriptive methods were used to analyze anticongulant causes,hemorrhagie susepibilityt factors and clinical characteristis.Patients were divided into the intemational normalized ratio(INR)overrange group and the INR non owerrange group according t0 INR value during bleeding.The Chi-square test,Sudent's test,and Wileoxon rank sum test were used to compare the diferences between the INR overrange group and the INR non overange group.The Wilcoxon rank sum test and Studen's test were used to analyze the charecteristis of gastrointestinal tract bleeding and cerebral hemorrhage.Results Warfarin-related major bleeding accounted for 0.36%(114/32040)of first aid cases and 9.84%(114/1158)of warfarin taking cases,respectively.Seventy-seven cases(67.5%)of anticoagulant causes were related 1to atrial filltion(AF)and 32 cases(28.1%)were related to post operative cardiac valve replacement.Of the bleeding susceptibility fanctors,HAS-BLED scored at 4.0(3.0,5.0),84 eass(73.7%)had a history of drug use,77 cases(67.5%)aged older than 65 years old,65 cases(57.0%)had iregular INR monitoring,and 29 cases(25.4%)had recent increase in dose.Forty cases(35.1%)were gastointesinal tmct bleeding with the lowest hemoglobin(Hb)value and the higest score of HAS-BLED.Twenty-one cases(18.4%)were cercbral hemorhage with the shorest protrombin time(PT).the lowest INR value,the bighest Hb.and the lowest score of HAS-BLED.Twelve cases(10.5%)died or gave u lreatment in eritieal condition,including 6 cases of cerebral hemorrhage.5 cases of gastrointestinal tract bleeding,and I case of hemoptysis.There were stistically signifcant dfferences in previous history of antiplitelet therapy,rcen incrsase in dose,HAS-BLED score and bleeding site between the INR owerrange group and the INR nor-verrange group(all P<0.05),Conclusions Among patients with warfarin-related major bleeding,AF and post-operative cardiasc valve replacement ane the main causes of warfarin anticoagulation.INR overrange is related to the previous history of antiplatelet therapy,rcent increase in dose,and the high score of HAS-BLED.The gstrintesinal tmact bleeding is the most common,with the lowest Hb value and the highest score of HAS-BLED.Cercbral bhemorrhage is the sccond common,with the shortest PT,the lowest INR valuc,and the highest Hb.The incidence and mortality nates of wfarin-elated major bleeding are relatively high.