Risk of thromboembolism with short-term interruption of warfarin therapy
Risk of thromboembolism with short-term interruption of warfarin therapy
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DOI：
10.1001/archinternmed.2007.23
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发表时间：
2008-01-14
影响因子：
--
通讯作者：
Hylek, Elaine M.
中科院分区：
文献类型：
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作者：
Garcia, David A.;Regan, Susan;Hylek, Elaine M.
背景：在侵入性手术前必须停止华法林钠治疗的患者的治疗存在很大的不确定性。在某种程度上，不确定性是由于缺乏与华法林短期治疗中断相关的血栓栓塞风险的公开信息。我们的目的是评估一大批因门诊侵入性手术而暂时停止华法林治疗的患者的血栓栓塞和出血的频率。方法：这项前瞻性、观察性队列研究在美国101个地点（主要是社区医生办公室实践）进行。入组时间为2000年4月4日至2002年3月6日。主要结局指标为华法林治疗中断后30天内血栓栓塞或有临床意义的出血。结果：共纳入1024例华法林治疗中断1293次。患者平均（SD）年龄为71.9（10.6）岁；女性438例（42.8%）。抗凝治疗最常见的适应症是房颤（550例）、静脉血栓栓塞（144例）和机械心脏瓣膜（13例）。最常见的手术是结肠镜检查、口腔和眼科手术。围手术期使用肝素或低分子肝素仅占总病例的8.3%。7名患者（0.7%；95%可信区间[CI]， 0.3%-1.4%）在30天内发生了术后血栓栓塞。7例发生血栓栓塞的患者均未接受围手术期桥接治疗。6名患者（0.6%;95% CI, 0.2%-1.3%）出现大出血，而另外17名患者（1.7%;95% CI, 1.0%-2.6%）出现临床显著的非大出血发作。在这23例有出血发作的患者中，14例接受了围手术期肝素或低分子肝素治疗。华法林治疗中断的时间是可变的；然而，超过80%的患者暂停华法林治疗5天或更少。结论：对于许多接受长期抗凝治疗的患者，他们需要进行小规模的门诊干预。
Background: Significant uncertainty surrounds the treatment of patients who must discontinue warfarin sodium therapy before an invasive procedure. In part, the uncertainty results from the lack of published information about the risk of thromboembolism associated with short-term warfarin therapy interruption. We aimed to assess the frequency of thromboembolism and bleeding within a large cohort of patients whose warfarin therapy was temporarily withheld for an outpatient invasive procedure.Methods: This prospective, observational cohort study was performed at 101 sites (primarily community-based physician office practices) in the United States. Enrollment was conducted from April 4, 2000, to March 6, 2002. The main outcome measures were thromboembolism or clinically significant hemorrhage within 30 days of warfarin therapy interruption.Results: A total of 1293 episodes of warfarin therapy interruption in 1024 individuals were included. The mean (SD) patient age was 71.9 (10.6) years; 438 (42.8%) were female. The most common indications for anticoagulant therapy were atrial fibrillation (n = 550), venous thromboembolism (n = 144), and mechanical heart valve (n = 13 2). The most common procedures were colonoscopy and oral and ophthalmic surgery. Perioperative heparin or low-molecular-weight heparin was used in only 8.3% of cases overall. Seven patients (0.7%; 95% confidence interval [CI], 0.3%-1.4%) experienced postprocedure thromboembolism within 30 days. None of the 7 patients who experienced thromboembolism received periprocedural bridging therapy. Six patients (0.6%; 95% CI, 0.2%-1.3%) experienced major bleeding, whereas an additional 17 patients (1.7%; 95% CI, 1.0%-2.6%) experienced a clinically significant, nonmajor bleeding episode. Of these 23 patients who had bleeding episodes, 14 received periprocedural heparin or low-molecular-weight heparin. The duration of warfarin therapy interruption was variable; however, more than 80% of patients had warfarin therapy withheld for 5 days or fewer.Conclusions: For many patients receiving long-term anticoagulation who need to undergo a minor outpatient intervention, a brief (