2023 年第 3 期 第 18 卷

心脏瓣膜病患者术后应用肝素钠与华法林抗凝致出血情况的比较及华法林抗凝致出血风险模型的构建

Comparison of anticoagulation induced bleeding between heparin sodium and warfarin in patients after valvular heart disease operation and construction of warfarin anticoagulation induced bleeding risk mode

作者：陈桂尼刘运仲王月婵陈少丽何瑞玲

英文作者：Chen Guini Liu Yunzhong Wang Yuechan Chen Shaoli He Ruiling

单位：海南医学院第一附属医院心胸外科，海口570102

英文单位：Department of Cardio-Thoracic Surgery the First Affiliated Hospital of Hainan Medical University Haikou 570102 China

关键词：心脏瓣膜病；肝素钠；华法林；出血风险；影响因素

英文关键词：Valvularheartdisease;Heparinsodium;Warfarin;Bleedingrisk;Influencingfactors

• 摘要：

• 目的 探讨心脏瓣膜病患者术后应用肝素钠与华法林抗凝致出血情况差异并构建华法林抗凝致出血风险模型。方法 选取2017年10月至2021年10月于海南医学院第一附属医院进行心脏机械瓣膜置换术的119例患者作为研究对象。按照随机数字表法将患者分为观察组（60例）和对照组（59例）。观察组术后口服华法林抗凝治疗，对照组术后皮下注射低分子肝素钠注射液抗凝治疗。比较2组患者治疗前后凝血指标和随访6个月血栓发生率、出血发生率，进行华法林治疗发生出血影响因素的单因素分析，采用多元Logistic回归方法分析华法林致出血的影响因素并构建风险预测模型，采用受试者工作特征曲线评估模型性能。结果 治疗后，2组患者的凝血酶原时间、活化部分凝血活酶时间、纤维蛋白原、凝血酶时间、D-二聚体、国际标准化比值均明显高于治疗前、且观察组高于对照组（均P＜0.05）。观察组血栓总发生率、总出血率低于对照组［3.3%（2/60）比13.6%（8/59）、21.7%（13/60）比39.0%（23/59）］（均P＜0.05）。多因素Logistic回归分析结果显示社会支持较差、抗凝知识知晓程度差、治疗依从性差、农村居住地、有嗜酒史、有吸烟史、病程长是心脏瓣膜病患者术后应用华法林发生出血的独立危险因素（均P＜0.05）；依据上述独立危险因素建立华法林致出血风险预测模型，受试者工作特征曲线分析结果显示，以上因素对华法林抗凝致出血风险有一定预测价值（曲线下面积＞0.7）。结论 心脏瓣膜病患者术后应用华法林抗凝治疗可以改善凝血指标，降低患者的血栓及出血发生率。通过对华法林致出血风险预测模型中的危险因素进行干预，预期可降低出血风险。

• Objective  To explore the comparison of anticoagulation induced bleeding between heparin sodium and warfarin in patients after valvular heart disease operation and to construct a warfarin anticoagulation induced bleeding risk model. Methods  From October 2017 to October 2021, totally 119 patients with mechanical heart valve replacement who were treated in the First Affiliated Hospital of Hainan Medical University were selected as the study subjects. According to the random number table method, they were divided into the observation group (60 cases) and the control group(59 cases). The patients in the observation group were given oral warfarin anticoa-gulant treatment after operation, and the patients in the control group were given low molecular weight heparin sodium anticoagulant treatment by subcutaneous injection after operation. The coagulation index before and after treatment, thrombosis incidence and bleeding incidence during 6 months follow-up between the two groups were compared. The single factor analysis of the influencing factors of bleeding in warfarin treatment was carried out. Multivariate Logistic regression analysis method was used to analyze the influencing factors of bleeding risk induced by warfarin, and a risk prediction model was constructed. The performance of the model was evaluated by the receiver operating characteristic curve. Results  After treatment, the indexes of prothrombin time, activated partial thromboplastin time, fibrinogen, thrombin time, D-dimer and international normalized ratio in the two groups were significantly higher than those before treatment, and the indexes in the observation group were significantly higher than those in the control group(all P<0.05). The total incidence of thrombosis and total bleeding rate in the observation group were lower than those in the control group［3.3%(2/60) vs 13.6%(8/59), 21.7%(13/60) vs 39.0%(23/59)］ (both P<0.05). Multivariate Logistic regression analysis showed that poor social support, poor awareness of anticoagulation knowledge, poor treatment compliance, rural residence, histories of alcoholism and smoking, and long course of disease were independent risk factors for bleeding in patients treated with warfarin after valvular heart disease operation (all P<0.05). The risk prediction model of warfarin induced bleeding was established based on the above independent risk factors. The receiver operating characteristic curve analysis showed that the above factors had certain predictive value for the risk of warfarin anticoagulation induced bleeding (area under the curve>0.7). Conclusions  Application of warfarin anticoagulant therapy in patients after valvular heart disease operation can improve coagulation indexes and reduce the incidences of thrombosis and bleeding. The risk of bleeding can be reduced by intervening to the risk factors of the risk prediction model of warfarin induced bleeding.