老年心房颤动高危患者抗凝治疗的药物选择及安全性

目的探讨老年心房颤动患者抗凝治疗的药物剂量选择及安全性。方法选择确诊的老年心房颤动患者210例,按照年龄将60～79岁130例作为老年段及≥80岁80例作为高龄段。2个年龄段患者按服药治疗不同分为老年华法林组30例、高龄华法林组30例,老年联合用药组50例(氯吡格雷75 mg+阿司匹林100 mg),老年阿司匹林组50例和高龄阿司匹林组50例(阿司匹林100 mg)。观察服用华法林剂量及国际标准化比值(INR);各组患者栓塞及出血发生率。结果高龄华法林组剂量(2.88±0.46)mg,INR 2.29±0.55,老年华法林组剂量(2.93±0.75)mg,INR 2.30±0.52,差异无统计学意义(P>0.05)。老年华法林组和高龄华法林组及老年联合用药组栓塞发生率明显低于老年阿司匹林组和高龄阿司匹林组(P<0.05)。与老年华法林组和高龄华法林组及老年阿司匹林组和高龄阿司匹林组比较,老年联合用药组出血发生率明显高(P<0.05)。结论老年心房颤动患者服用华法林或氯吡格雷+阿司匹林能更有效预防脑卒中事件的发生,老年、尤其是高龄高危患者服用华法林治疗,INR控制在1.5～2.5是安全、有效。对于不适合应用华法林的患者,可应用氯吡格雷+阿司匹林预防血栓形成。     

80岁及以上心房颤动患者低强度抗凝治疗的安全性和疗效观察

目的 评价年龄80岁及以上非瓣膜性心房颤动患者低强度抗凝治疗的疗效和安全性.方法入选年龄80岁及以上住院非瓣膜性心房颤动患者180例,随机抽签分为低强度和标准强度华法林抗凝治疗,低强度组目标国际标准化比值(INR)1.6～2.0,标准强度组目标INR 2.0～3.0.主要观察终点为两组患者随访期间各种出血并发症及各种栓塞事件发生率;次要观察为INR达标需要的华法林剂量,随访中INR＞3.0的测定次数.结果 两组患者均在半个月内达标,其后随访1年,随访期间低强度组和标准强度组血栓栓塞事件发生率分别为4.4%(4/90)与3.3%(3/90),差异无统计学意义(P＞0.05).但各种出血事件低强度组低于标准强度组,分别为5.6%(5/90)与16.7%(15/90),差异有统计学意义(P＜0.05),同时华法林使用剂量低强度组低于标准强度组,分别为(1.55±0.63)mg与(2.31±0.57)mg,差异有统计学意义(P＜0.05),随访中INR＞3.0的次数低强度组亦少于标准强度组(P＜0.05).结论 在年龄80岁及以上非瓣膜性心房颤动患者中,采用目标INR1.6～2.0低强度抗凝治疗,较常规标准抗凝治疗疗效差异无统计学意义,出血事件及风险明显减少.

Abstract：

Objective To investigate the effectiveness and safety of low-intensity warfarin anticoagulation in over 80-year-old patients with nonvascular atrial fibrillation (NVAF). Methods The 180 NVAF patients aged over 80 years were randomly assigned into 2 groups: 90 patients in lowintensity warfarin anticoagulation group (target value of INR 1.6-2.0), the other 90 patients in standard-intensity warfarin anticoagulation group (target value of INR 2. 0-3.0). All patients were followed up in outpatient-department for one year. Main outcome measures included the incidence rates of bleeding and thromboembolic events, and secondary outcome measures included the warfarin dosage and times of INR＞3.0. Results The incidence rate of thromboembolic events was 4.4% (4/90) in low-intensity group and 3.3% (3/90) in standard-intensity group with no statistically significant difference between these two groups (P＞0. 05). However, the incidence rate of hemorrhage was significantly lower in low-intensity group than in standard-intensity group [5.6% (5/90) vs. 16.7%(15/90), P＜0. 05]. Meanwhile the warfarin dosage was significantly lower in low-intensity group than in standard-intensity group [(1. 55±0. 63) mg vs. (2.31±0.57) mg, P＜0.05]. The times of INR＞3.0 were less in low-intensity group than in standard-intensity group (P＜0. 05). Conclusions Therapy with low-intensity warfarin anticoagulation in NVAF patients aged over 80 years may be equally effective as, but safer than that with standard-intensity warfarin.     

高危患者心脏起搏器植入术后华法林抗凝治疗的疗效及安全性

目的研究高危患者在心脏起搏器植入术后应用华法林抗凝治疗预防血栓形成的有效性。方法将96例心脏起搏器植入患者随机分为抗凝组与对照组,抗凝组于起搏器植入术后给予口服华法林。两组于术后6个月行数字减影血管造影检查。结果抗凝组16例（34%）出现静脉阻塞,对照组27例（58.7%）出现静脉阻塞,抗凝组降低绝对风险23.5%（相对风险0.57,95%可信区间0.33~0.98）。抗凝组38例（76%）PT/APTT在正常范围内。结论心脏起搏器植入术后的抗凝治疗是安全有效的,可以降低高危患者发生静脉阻塞的风险。     

华法林抗凝治疗中出血和血栓栓塞性不良反应及相关因素探讨

目的 研究华法林抗凝治疗过程中出血和血栓栓塞性不良反应并识别相关危险因素。方法 观察北京大学人民医院2001-04～2003-11抗栓门诊华法林使用大于4周患者的出血和血栓栓塞事件，事件分为小事件、严重事件和威胁生命或致命性事件，应用多种统计方法分析出血和血栓栓塞事件发生情况及相关危险因素。结果 128例服用华法林患者，平均年龄67岁（25—83岁），34例（占26．6％）共发生41次出血事件，严重和致命性的血栓栓塞事件5例（占3．9％）。年龄、肝硬化与出血事件显著相关（P=0．040，P=0．014）。结论 出血是华法林抗凝治疗最主要的不良反应，而年龄、肝硬化是出血事件的重要危险因素。     

消化性溃疡出血的内镜治疗

内镜能有效地治疗消化性溃疡出血,降低病人的急诊手术率、再出血率和输血量,并可能降低其死亡率。内镜下止血方法较多,但以热凝疗法和注射疗法为佳。     

华法林预防心房颤动患者血栓栓塞55例临床观察

临床试验证实华法林能使非瓣膜房颤脑卒中的年发生率从4 5 %下降到1 4% ,且比阿司匹林更有效〔1〕。但仍有相当比例的房颤患者未应用华法林,栓塞并发症的降低仍未令人满意,其主要原因在于应用华法林过程中,存在出血并发症发生率较高以及频繁采血检测抗凝指标影响了患者服药顺应性〔2〕。本文对有血栓栓塞危险的房颤病人应用不同抗凝强度华法林预防房颤患者血栓形成情况进行临床观察。1　资料与方法1 1　研究对象　1999年4月～2 0 0 2年5月在我院住院及门诊就诊的各种器质性心脏病、高血压、糖尿病、心功能不全、缺血性中风等血栓栓塞危险因…     

华法林对高危持续性心房颤动患者血栓前状态和心功能的影响

目的探讨调整剂量华法林[国际标准化比值（INR）23]对高危持续性心房颤动（AF）患者血栓前状态和心功能的影响。方法99例高危持续性AF患者随机给予阿司匹林（100mg/d,阿司匹林组）或调整剂量华法林（华法林组）治疗1年。于治疗前、治疗后6个月和12个月分别检测血栓前状态（PTS）各分子标志物,采用免疫比浊法测定D-二聚体水平,采用ELISA双抗体夹心法测定血小板α-颗粒膜蛋白（GMP）-140、血浆血栓调节蛋白（TM）和血浆凝血酶-抗凝血酶Ⅲ复合物（TAT）水平;超声测定心排出量（CO）和左室射血分数（LVEF）,进行前后比较分析。随访中观察有无血栓栓塞和出血并发症发生。结果①与阿司匹林组比较,华法林组治疗6个月、12个月后D-二聚体、GMP-140、TAT、TM水平均显著降低,CO、LVEF均显著增加（P<0.05）;②随访期间两组均无血栓栓塞事件发生,华法林组有1例出现上消化道大出血,经治疗痊愈。结论调整剂量华法林能不同程度地改善高危AF患者的血栓前状态和心功能,疗效优于阿司匹林,治疗是安全的。     

城郊高龄老年房颤患者华法林治疗的安全性

目的：探讨城郊高龄老年房颤患者应用华法林的安全性.方法：选择100例资料完整的老年房颤患者,按照数字表法,被随机分为华法林组（51例）：华法林起始剂量1.25 mg,1次/d.每隔3d测定血浆凝血酶原时间国际标准化比值（INR）1次.2～4周达到目标范围,如INR未达标,每隔1周增加华法林0.625 mg,直到INR控制在2.0～3.0.INR稳定前门诊随访每周监测1次,INR稳定后每4周监测1次;阿司匹林组（49例）：阿司匹林,100 mg,1次/d.结果：与阿司匹林组比较,华法林组血栓栓塞等终点事件发生率明显降低（19.15％比3.92％,P=0.017）,出血等不良反应发生率无显著差异（4.25％比5.88％,P＞0.05）.结论：高龄老年房颤患者应用华法林,能显著降低栓塞发生率,而且是安全的.     

全程管理模式在心脏瓣膜置换术后患者抗凝治疗中的应用观察

目的 观察全程管理模式在心脏瓣膜置换术后患者抗凝治疗中的应用效果.方法 选择心脏瓣膜置换术后患者208例为观察组,在抗凝治疗中采用多学科协作一站式抗凝门诊联合信息化随访平台的全程管理模式,进行覆盖门诊+社区的抗凝管理.另选择同期在普通门诊进行随访的208例心脏瓣膜置换术后患者为对照组.随访期间采用修订后...     

老年心房颤动患者抗栓治疗现状与安全性和疗效的对比研究

目的观察老年心房颤动(房颤)患者抗栓治疗现状与安全性和疗效的对比研究。方法选择老年房颤患者343例,根据抗栓治疗不同分为无抗栓组56例,阿司匹林组120例,氯吡格雷组24例,联合组20例(阿司匹林+氯吡格雷),华法林组106例,新型口服抗凝药(NOAC)组17例。分析各组血栓栓塞和出血事件发生情况。结果无抗栓组、阿司匹林组、氯吡格雷组、联合组、华法林组和NOAC组栓塞发生率比较,差异有统计学意义(48.2%vs37.5%vs 25.0%vs 25.0%vs 5.7%vs 5.9%,χ~2=76.02,P=0.000)。总出血发生率华法林组为13.2%,阿司匹林组为11.7%,联合组为10.0%,无抗栓组为5.4%,NOAC组为5.9%,氯吡格雷组为0,各组出血发生率比较,差异有统计学意义(χ~2=17.14,P<0.01)。结论老年房颤患者必须行抗栓治疗以减少脑卒中等栓塞事件发生风险,在抗栓治疗中首选华法林或NOAC治疗,NOAC在栓塞预防及出血风险方面并不优于华法林,尤其在中重度肾功能不全应注意大出血风险。     

Outcomes and total costs of outpatient vs. inpatient peri-procedural anticoagulation management of mechanical prosthetic heart valve patients

Background/objectives

The most cost-effective periprocedural management of patients with mechanical heart valves (MHV) is uncertain. The objective was to compare the effectiveness, safety and costs for inpatient intravenous unfractionated heparin (IVUH) vs. outpatient low molecular weight heparin (LMWH) “bridging” as periprocedural anticoagulation management for MHV patients.

Methods

In a case-cohort study, Olmsted County, MN residents with MHV who received outpatient periprocedural LMWH management (cases) over the 11-year period, 1997–2007, were matched to residents with MHV who received inpatient IVUH periprocedural management on valve location and type, and on procedure type. Patients were followed for 3 months following hospitalization to identify thromboembolism (TE) and major bleeding. Total costs from 30 days before to 90 days after the procedure were determined from the Olmsted County Healthcare Expenditure and Utilization Database. Outcomes were compared using survival analysis and costs were compared using the Wilcoxon rank sum.

Results

149 cases (100 aortic, 29 mitral, 20 both; 64% bileaflet) were compared to 149 cohort members (100 aortic, 29 mitral, 20 both; 75% bileaflet). While the 3-month cumulative incidence of TE did not differ significantly among cases (2.7%) and cohort members (4.7%; p = 0.36), major bleeding was significantly lower in cases (5.4% vs. 15.4%; p < 0.005). Total costs were significantly higher for cohort members ($50,984 vs. $39,347; p = 0.002) due to higher inpatient costs ($47,729 vs. $34,860; p = 0.0002).

Conclusions

Outpatient bridging LMWH therapy is equally effective, but safer and less costly than inpatient IVUH as periprocedural anticoagulation management for MHV patients.     

Effectiveness and safety of a management protocol to correct over-anticoagulation with oral vitamin K: a retrospective study of 1,043 cases

Background Timely reversal of excessive anticoagulation is important in preventing bleeding complications. The use of vitamin K in correcting over-anticoagulation is widely accepted to be superior to discontinuation of therapy but its effectiveness and safety in large scale cohort studies has not been assessed. Methods According to our protocol, 2 mg of oral vitamin K in addition to omitting the day’s dose of warfarin, were administered to all patients presenting INR levels ≥5.0 and below 10.0; the INR values were checked 20 h after vitamin K administration. The rate of decay of INR, bleeding and thromboembolic complications at presentation and the following 30 days, as well as resistance to warfarin were assessed. Results Of the 1,611 events, 1,043 (878 patients) met the selection criteria. The median (interquartile range) INR was 6.64 (6.12–7.52) at presentation (day zero) and fell to a median (interquartile range) INR of 2.72 (2.18–3.52, P < 0.0001) after the vitamin K administration (day one) and 90.6% of the INRs were below 4.5. In 98 (9.4%) instances the INR values did not fall below the safe limit of 4.5 and in 173 (17%) instances the INR values were overcorrected to below 2.0. Median INR value on day zero in these two groups was higher (7.3 vs. 6.6, P < 0.0001) and lower (6.5 vs. 6.7, P = 0.049) than that of the remaining cases, respectively. Overcorrection occurred more frequently in women (P = 0.0002). Female gender was an independent factor associated with INR overcorrection (P = 0.001; OR = 1.7, 95% CI 1.3–2.3). The INRs on day one were inside, above and below the therapeutic range in 44%, 36% and 20% respectively. Warfarin resistance was observed in six cases (0.6%). Major bleeding was reported in one case (1.1 per 100 patient-years), minor bleeding in 14 cases (16.1 per 100 patient-years) and thromboembolic events in six high risk patients (6.9 per 100 patient-years) during the one month period following vitamin K administration. Conclusions This adopted protocol for the reversal of excessive anticoagulation in asymptomatic or minor symptom presenting patients is easily applied, effective in lowering the INR and preventing complications. Its use in high risk thromboembolic patients warrants caution.     

华法林在慢性心房颤动抗凝治疗中的应用

目的:探讨华法林在慢性心房颤动(CAf)抗凝治疗中的合理应用。方法:共入选234例具有血栓栓塞高风险的CAf患者,给予华法林抗疑治疗,监测国际标准化比值(INR)以调整华法林用量,随访观察华法林的不同起始剂量、不同的抗凝强度以及高龄(≥65岁)等因素对INR达标时间、INR稳定值、华法林维持量、出血率及栓塞率的影响。结果:分别采用开始剂量为普通剂量(2．5mg／d)与小剂量(1．25 mg／d)2种方式,两者最终获得稳定的INR、华法林维持量及出血率均差异无统计学意义,但前者能明显缩短INR首次达标时间及获得INR 稳定值的时间(均P<0．01),并有降低栓塞率的趋势;与低强度抗凝相比,中强度抗凝能显著降低栓塞率(P< 0．05),虽然伴出血率明显升高(P<0．05),但无严重出血发生;在相同的目标INR内,高龄患者出血率并不增加,但所需的华法林维持量有所降低(P<0．01)。结论:以普通量的华法林开始CAf抗凝治疗是安全的,抗栓塞效果优于小剂量;对具有栓塞高风险的CAf需保持中强度抗凝水平;华法林抗凝治疗并不增加高龄患者的出血风险。     

孤立性食管静脉瘤223例临床内镜分析

目的通过分析内镜诊断为食管孤立性静脉瘤223例患者的临床内镜特点,以加深内镜医师对该病的认识,减少对该病的误诊。 方法对2013年6月至2018年1月宁夏回族自治区人民医院消化内镜中心通过胃镜诊断的食管孤立性静脉瘤进行分析。 结果期间共完成胃镜诊断48 861例,其中食管孤立性静脉瘤223例,检出率为0.46%,其中5例因出血行内镜下食管静脉瘤硬化术。 结论：食管孤立性静脉瘤属良性病变,增长速度缓慢,一般无特殊处理,若发生出血,内镜下注射聚桂醇硬化治疗为可行有效的方法。     

老年人胃食管黏膜病变内镜黏膜下剥离术的安全性探讨

目的 探讨60岁以上老年人胃食管黏膜病变内镜黏膜下剥离术(ESD)治疗的安全性.方法 经胃镜检查发现胃食管扁平隆起性病变的老年患者36例,病理活检及内镜超声检查证实为异型增生14例,早期癌9例,平滑肌瘤13例.在清醒状态下,应用改良的针状钩刀、IT刀及电凝电切技术剥离病灶,应用去甲肾上腺素冰生理盐水、氩气刀、金属夹等处理创面.术后4周复查胃镜评价创面愈合及病灶残留情况.结果 36例中,ESD完整切除病灶29例(80.6%),借助圈套器切除7例(19.4%).术中穿孔3例(8.3%),经金属夹闭合、胃管引流、禁食、抑酸和抗感染等治疗,5～7d恢复;术后2h出现呕血1例(2.8%),经内镜下金属夹止血.结论 对老年胃食管黏膜病变患者行ESD治疗是安全有效的.     

Profile of Czech AF 2012. Profile of atrial fibrillation patients receiving antithrombotic therapy

The profile of Czech AF 2012 is an epidemiological survey conducted by 197 Czech internal medicine and cardiology specialists who aimed to provide a comprehensive view of patients with non-valvular atrial fibrillation and their treatment in the Czech Republic. Each specialist had to include 5 consecutive patients.It involved 982 patients with an average age of 69.9 ± 10.04 years. The population of men was slightly higher (n = 543, 55.3%), especially in the under 65 years age group; women were the majority in the age group above 75 years (44.3% of men, 55.7% of women).One quarter (25.1%) of patients were diagnosed with atrial fibrillation for less than 2 years; 23.2% for 2–5 years; 13.5% for 6–10 years, and 8.6% for more than 10 years. 20.7% of patients had paroxysmal atrial fibrillation; 58.5% indicated permanent atrial fibrillation, i.e. lasting more than one year. 58.7% of patients received medication to regulate heart rhythm; 44.0% had another antiarrhythmic medication. 13.8% of patients used their medication once a day; 55.1% twice a day, and 29.6% three times a day. 38.7% of patients were after cardioversion, 7.9% were after ablation. 91.5% of patients received warfarin alone or as dual (1.4%) therapy. Only 8.7% of patients had medium or severe kidney impairment. Only 7.5% of patients used acetylsalicylic acid, 0.2% used dual antiplatelet treatment.Only 3.0% of patients had CHADS2 = 0; 55.8% were at a medium risk (CHADS2 = 1–2), and 41.2% at a high risk (CHADS2 > 2). 22.1% had one associated condition; 27.5% had two associated conditions; 19.8% had three associated conditions; 28.7% had four or more associated conditions; and only 2.0% indicated no associated condition or gave no answer. The most common associated condition was hypertension (90.2%), followed by ischemic heart disease (50.9%) and diabetes mellitus (41.8%).95 patients (9.7%) had a history of embolism while receiving antithrombotic therapy. 102 patients (10.4%) had a clinically significant bleeding event while on antithrombotic therapy, 51 patients needed hospitalization.The average frequency of INR measurements was 10.2 per year (10.4 by cardiologists, 10.1 by internal medicine specialists). 61.6% were within the INR therapeutic range of 2–3.ConclusionAtrial fibrillation patients are commonly elderly, polymorbid and high-risk patients on a pharmacological medication two to three times a day. INR monitoring was close to the level described in large international studies, almost 2/3 of patients were within the therapeutic range.     

Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures： A three year prospective study

AIM: To analyze the hemodynamic and respiratory effects of propofol on patients undergoing gastroscopy and colonoscopy. METHODS: In this prospective study, conducted over a period of three years, 1,104 patients referred for a same day GI endoscopy procedure were analyzed. All patients were given a propofol bolus (0.5-1.5 mg/kg). Arterial blood pressure (BP) was monitored at 3 min intervals and heart rate and oxygen saturation (SpO2) were recorded continuously by pulse oximetry. Analyzed data acquisition was carried out before, during, and after the procedure. RESULTS: A statistically significant reduction in mean arterial pressure was demonstrated (P<0.001) when compared to pre-intervention values, but severe hypotension, defined as a systolic blood pressure below 60mmHg, was noted in only 5 patients (0.5%). Oxygen saturation decreased from 96.5% to 94.4 % (P<0.001). A critical decrease in oxygen saturation (<90%) was documented in 27 patients (2.4%). CONCLUSION: Our results showed that propofol provided good sedation with excellent pain control, a short recovery time and no significant hemodynamic side effects if carefully titrated. All the patients (and especially ASA III group) require monitoring and care of an anes- thesiologist.     

老年人胃食管黏膜病变内镜黏膜下剥离术的安全性探讨

目的 探讨60岁以上老年人胃食管黏膜病变内镜黏膜下剥离术(ESD)治疗的安全性.方法 经胃镜检查发现胃食管扁平隆起性病变的老年患者36例,病理活检及内镜超声检查证实为异型增生14例,早期癌9例,平滑肌瘤13例.在清醒状态下,应用改良的针状钩刀、IT刀及电凝电切技术剥离病灶,应用去甲肾上腺素冰生理盐水、氩气刀、金属夹等处理创面.术后4周复查胃镜评价创面愈合及病灶残留情况.结果 36例中,ESD完整切除病灶29例(80.6%),借助圈套器切除7例(19.4%).术中穿孔3例(8.3%),经金属夹闭合、胃管引流、禁食、抑酸和抗感染等治疗,5～7d恢复;术后2h出现呕血1例(2.8%),经内镜下金属夹止血.结论 对老年胃食管黏膜病变患者行ESD治疗是安全有效的.     

华法林对中国人心房颤动患者抗栓的安全性和有效性研究

目的　通过回顾性分析心房颤动 (房颤 )患者的抗栓治疗 ,初步探讨中国人华法林国际标准化率 (INR)的合理范围。方法　调查 4 35例房颤患者应用华法林抗凝及INR监测情况 ,分析出血和血栓栓塞事件的危险因素及与INR的关系。结果　华法林疗程时间中位数 7个月 ,平均剂量为(2 77± 0 83)mg。共发生出血事件 31例 (7 11% ) ,其中严重出血 5例 ,轻微出血 2 6例。发生出血患者年龄略高于对照组 [(6 5 1± 10 0 )岁与 (6 2 0± 12 2岁 ) ],但差异无统计学意义 (P =0 2 5 9) ;出血患者血压高于对照组 ,合并心力衰竭较多 (P =0 0 5 )。多因素分析中INR≥ 3为预测出血的独立危险因素 (OR =3 74 )。血栓栓塞事件 37(17 4 7% )例 ,发生缺血性卒中或栓塞的危险随INR下降明显增加。结论　房颤患者华法林抗凝目标INR值应避免低于 1 5或高于 3 0。