CHA_(2)DS_(2)-VASc评分在老年髋部骨折伴非瓣膜性心房颤动患者围手术期抗凝中的应用

Application of CHA_(2)DS_(2)-VASc score in perioperative anticoagulation of elderly hip fracture patients with non-valvular atrial fibrillation

目的探讨血栓栓塞风险评分(CHA_(2)DS_(2)-VASc评分)在老年髋部骨折伴非瓣膜性心房颤动(NVAF)患者围手术期分层抗凝管理中的应用效果。方法回顾性纳入78例老年髋部骨折伴NVAF患者,根据术前CHA_(2)DS_(2)-VASc评分对患者年龄、性别、糖尿病、高血压、心力衰竭、脑卒中及血管疾病史进行评分,并将患者分成3组:低危组(≤1分,18例)、中危组(>1~2分,36例)、高危组(>2分,24例),3组患者术前5 d均改用低分子肝素桥接抗凝,术后24~48 h分别予阿司匹林、利伐沙班、低分子肝素分层抗凝。比较3组患者的一般临床资料、术中出血量、术后引流量和血红蛋白量、围手术期国际标准化比值(INR)、术后1年并发症的发生率、术后1年老年髋部骨折功能恢复量表(FRS)评分。结果低、中、高危组患者的CHA_(2)DS_(2)-VASc评分分别为(0.56±0.48)、(1.73±0.23)和(5.62±0.76)分,3组比较差异有统计学意义(P<0.01)。3组患者的性别差异无统计学意义(P=0.506)。3组患者年龄差异有统计学意义(P<0.01),低危组年龄最小,高危组年龄最大。中、高危组有既往糖尿病、高血压、充血性心力衰竭、缺血性脑卒中或短暂性脑缺血发作(TIA)及血管疾病史的患者比例均较低危组高,差异均有统计学意义(P均<0.05);高危组有既往缺血性脑卒中或TIA史的患者比例较中危组高,差异有统计学意义(P=0.031);中危组与高危组有既往心力衰竭、高血压、糖尿病及心血管疾病的患者比例差异均无统计学意义(P均>0.05)。3组患者手术时间、术中出血量、术后引流量,术前、术后1 d、术后3 d血红蛋白水平和INR,术后1年缺血性/出血性脑卒中、急性冠状动脉综合征、深静脉血栓的发生率,以及术后1年FRS评分差异均无统计学意义(P均>0.05),且3组均无死亡病例。结论CHA_(2)DS_(2)-VASc评分可根据血栓风险因素指导老年髋部骨折伴NVAF患者围手术期抗凝药物的分级使用策略。

Objective To explore the application of CHA_(2)DS_(2)-VASc score in perioperative stratified anticoagulation for elderly hip fracture patients with non-valvular atrial fibrillation(NVAF).Methods A total of 78 elderly hip fracture patients with NVAF were enrolled.Age,gender,diabetes mellitus,hypertension,heart failure,stroke and vascular disease history were scored according to the preoperative CHA_(2)DS_(2)-VASc score,and the patients were divided into 3 groups:low-risk group(CHA_(2)DS_(2)-VASc score≤1,18 cases),medium-risk group(CHA_(2)DS_(2)-VASc score>1-2,36 cases),and high-risk group(CHA_(2)DS_(2)-VASc score>2,24 cases).Three groups were all switched to low molecular heparin for bridging anticoagulation 5 days before operation,and treated with aspirin,rivaroxaban and low molecular heparin for stratified anticoagulation 24-48 h after operation.The general clinical data,intraoperative blood loss,postoperative drainage and hemoglobin,perioperative international normalized ratio(INR),incidence of complications in 1 year after operation and the elderly hip fracture functional recovery scale(FRS)score were compared among the 3 groups.Results The CHA_(2)DS_(2)-VASc scores of patients in the low-,medium-and high-risk groups were 0.56±0.48,1.73±0.23 and 5.62±0.76,respectively,showing significant differences(P<0.01).There was no significant difference in gender among the 3 groups(P=0.506).There was significant difference in age among the 3 groups(P<0.01),with patients in the low-risk group being the youngest and those in the high-risk group being the oldest.Compared with the low-risk group,the proportions of patients with previous diabetes mellitus,hypertension,congestive heart failure,ischemic stroke or transient ischemic attack(TIA),and vascular disease were significantly higher in the medium-and high-risk groups(all P<0.05);the proportion of patients with previous ischemic stroke or TIA was significantly higher in the high-risk group than in the medium-risk group(P=0.031);there were no significant differences in the proportions of patients with previous heart failure,hypertension,diabetes mellitus or cardiovascular disease between the medium-and high-risk groups(all P>0.05).There were no significant differences in operation time,intraoperative blood loss,postoperative drainage,hemoglobin levels or INR before,1 d after,and 3 d after operation among the 3 groups,and the same was true for the incidences of ischemic/hemorrhagic stroke,acute coronary syndrome,deep vein thrombosis,and FRS scores 1 year after operation(all P>0.05).There were no deaths among the 3 groups.Conclusion The CHA_(2)DS_(2)-VASc score can guide the use of perioperative stratified anticoagulants in elderly hip fracture patients with NVAF according to the risk factors of thrombosis.