心房颤动合并急性冠状动脉综合征患者住院期间发生出血的危险因素

Risk factors of bleeding in atrial fibrillation patients with acute coronary syndrome during hospitalization

目的分析心房颤动合并急性冠状动脉综合征(ACS)患者住院期间发生出血的危险因素。方法回顾性分析首都医科大学附属北京同仁医院2016年1月至2018年12月收治的237例心房颤动合并ACS患者临床资料。根据患者入院后是否发生出血分为未出血组(181例)和出血组(56例)。收集患者的临床资料,分析出血组的出血严重程度和出血类型,比较有无出血组患者年龄、性别、吸烟史、饮酒史、心房颤动类型、ACS分型,经皮冠状动脉介入和冠状动脉旁路移植比例,合并疾病、既往史、CHA2DS2-VASc评分、HAS-BLED评分及应用药物情况,比较住院期间不同抗栓治疗方案患者的出血发生率。结果 56例出血患者中严重或威胁生命的出血3例,均为消化道出血,中度出血4例(1.7%),轻微出血49例(20.7%)。出血组<60岁、不稳定型心绞痛、肌酐清除率> 60 ml/min、既往冠心病史比例均低于未出血组,高脂血症、纽约心脏病协会心功能Ⅲ~Ⅳ级、高尿酸血症、感染性疾病、低蛋白血症、贫血、肝功能异常、肌酐清除率30~60 ml/min比例均高于未出血组(均P <0.05)。出血组HAS-BLED评分≥3分比例高于未出血组,0~2分比例低于未出血组(均P <0.05)。用药情况比较,出血组患者应用胺碘酮、质子泵抑制剂、利尿剂、抗感染药物比例均高于未出血组(均P <0.05)。住院期间不同抗栓方案患者的出血发生率比较差异无统计学意义(P> 0.05)。结论高龄、纽约心脏病协会心功能Ⅲ~Ⅳ级、肝肾功能异常,合并贫血、低蛋白血症、感染性疾病,联合使用胺碘酮、利尿剂、抗感染药物的心房颤动合并ACS患者出血风险高,HAS-BLED评分在预测出血风险方面具有一定意义。

Objective To analyze the risk factors of bleeding in atrial fibrillation patients with acute coronary syndrome( ACS) during hospitalization. Methods The clinical data of 237 atrial fibrillation patients with ACS admitted to Beijing Tongren Hospital,Capital Medical University from January 2016 to December 2018 were retrospectively analyzed. According to whether bleeding occurred after admission,the patients were divided into non bleeding group( 181 cases) and bleeding group( 56 cases). The clinical data of patients were collected,and the bleeding severity and bleeding type of the bleeding group were analyzed. The age,gender,smoking history,drinking history,type of atrial fibrillation,ACS classification,proportion of percutaneous coronary intervention and coronary artery bypass grafting,comorbidity,past history,CHA2 DS2-VASc score,HAS-BLED score and drugs use were compared between bleeding group and non bleeding group. The incidence of bleeding in patients with different antithrombotic therapy during hospitalization was compared. Results Among the 56 cases of bleeding,3 cases had serious or life-threatening bleeding which were gastrointestinal bleeding,4 cases( 1. 7%) were moderate bleeding,and 49 cases( 20. 7%) were mild bleeding. The proportions of age < 60 years old,unstable angina pectoris,creatinine clearance rate > 60 ml/min and prior coronary atherosclerotic heart disease history in bleeding group were lower than those in non bleeding group;the proportions of hyperlipidemia,New York Heart Association( NYHA) cardiac function grade Ⅲ-Ⅳ,hyperuricemia,infectious diseases,hypoproteinemia,anemia,abnormal liver function and creatinine clearance rate of 30-60 ml/min in bleeding group were higher than those in non bleeding group( all P < 0. 05). The proportion of HAS-BLED score ≥3 in bleeding group was higher than that in non bleeding group,and the proportion of HAS-BLED score of 0-2 in bleeding group was lower than that in non bleeding group( both P < 0. 05). In terms of medication,the proportions of using amiodarone,proton pump inhibitors,diuretics and anti infective drugs in bleeding group were higher than those in non bleeding group( all P < 0. 05). There was no significant difference in the incidence of bleeding among patients with different antithrombotic regimens during hospitalization( P > 0. 05). Conclusions The elderly,NYHA cardiac function grade Ⅲ-Ⅳ,abnormal liver and kidney function,anemia,hypoproteinemia,infectious diseases,and use of anti infective drugs in atrial fibrillation patients with ACS have high risk of bleeding. The HAS-BLED score has certain significance in predicting the risk of bleeding.