Predictors of major bleeding in peri-procedural anticoagulation management
Predictors of major bleeding in peri-procedural anticoagulation management
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DOI：
10.1111/j.1538-7836.2011.04572.x
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发表时间：
2012-02-01
影响因子：
10.4
通讯作者：
Heit, J. A.
中科院分区：
文献类型：
--
作者：
Tafur, A. J.;McBane, R., II;Heit, J. A.
。背景：对长期抗凝治疗的患者进行适当的围手术期管理需要评估患者特异性的血栓形成和出血风险。然而，术后出血的预测因素尚不清楚。目的：确定因侵入性操作而需要暂时中断华法林的长期抗凝患者围手术期出血的 3 个月累积发生率和独立预测因素。方法：在方案驱动的队列研究设计中，所有转诊至 Mayo Clinic 血栓形成倾向中心进行围手术期抗凝管理的患者 (19972007；n = 2182)，均及时随访以确定围手术期出血的 3 个月累积发生率（KaplanMeier 积限）和出血的潜在预测因素（Cox 比例风险）。使用低分子量肝素桥接的决定是基于估计的血栓栓塞和出血风险。结果：长期抗凝治疗的适应症包括静脉血栓栓塞（38%）、心房颤动（30%）和机械心脏瓣膜（27%）。其中，1496 名 (69%) 患者接受了桥接治疗。大出血和总体出血的 3 个月累积发生率分别为 2.1% 和 5.1%。接受桥接治疗的患者发生大出血的频率更高（3% vs. 1%；P = 0.017）。大出血的独立预测因素（风险比；95%置信区间）包括二尖瓣机械心脏瓣膜（2.2；1.14.3）、活动性癌症（1.8；1.03.1）、既往出血史（2.6；1.54.5）和术后24小时内重新开始肝素治疗（1.9；1.13.4）。结论：围手术期出血的诱发因素主要是患者特异性的。过早重新启动肝素是一个需要考虑的可避免的特定于提供者的变量。
. Background: Appropriate periprocedural management for chronically anticoagulated patients requires assessment of patient-specific thrombosis and bleeding risks. However, predictors of post-procedure bleeding are unknown. Objectives: To determine the 3-month cumulative incidence and independent predictors of peri-procedural bleeding in chronically anticoagulated patients requiring temporary warfarin interruption for an invasive procedure. Methods: In a protocol driven, cohort study design, all patients referred to the Mayo Clinic Thrombophilia Center for peri-procedural anticoagulation management (19972007; n = 2182), were followed forward in time to determine the 3-month cumulative incidence of peri-procedural bleeding (KaplanMeier product limit) and potential predictors of bleeding (Cox proportional hazards). Decisions to bridge with low-molecular-weight heparin were based on estimated thromboembolism and bleeding risk. Results: Indications for chronic anticoagulation included venous thromboembolism (38%), atrial fibrillation (30%) and mechanical heart valves (27%). Of these, 1496 (69%) patients received bridging therapy. The 3-month cumulative incidence rates of major and overall bleeding were 2.1% and 5.1%, respectively. Major bleeding occurred more frequently in patients receiving bridging therapy (3% vs. 1%; P = 0.017). Independent predictors (hazard ratio; 95% confidence interval) of major bleeding included mitral mechanical heart valve (2.2; 1.14.3), active cancer (1.8; 1.03.1), prior bleeding history (2.6; 1.54.5) and re-initiation of heparin therapy within 24 h after the procedure (1.9; 1.13.4). Conclusion: Factors predisposing to peri-procedural bleeding are primarily patient-specific. Premature heparin re-initiation is an avoidable provider-specific variable to consider.