围手术期患者应长期抗栓治疗

导读手术操作可以分为通常不需要完全撤销抗凝治疗的低出血风险，以及一些与中等或高出血风险相关的操作。围手术期还必须考虑抗血小板药物，还需特别考虑冠状动脉支架患者抗血小板治疗抑制期血栓并发症的潜在风险。

　　围手术期抗凝治疗是一种常见的且需要考虑患者、手术和扩大抗凝和抗血小板药物排列的情况。术前评估必须解决的是：与围手术期出血风险相平衡的栓塞事件的风险。手术操作可以分为通常不需要完全撤销抗凝治疗的低出血风险，以及一些与中等或高出血风险相关的操作。如果接受华法林的患者需要中断抗凝，必需考虑的是简单地阻断抗凝是否是一种最佳的方法，或者是否该使用一种可替代药物作为围手术期的"桥接"，通常该药物是低分子肝素。新型口服抗凝血剂达比加群和利伐沙班有更短的有效半衰期，但他们引起了围手术期治疗的其他问题，包括肾功能不全患者药物作用时间的延长，关于确定无残留抗凝效应的临床试检测试经验的有限性，且缺乏逆转剂。围手术期还必须考虑抗血小板药物，还需特别考虑冠状动脉支架患者抗血小板治疗抑制期血栓并发症的潜在风险。相关研究见（Hematology Am Soc Hematol Educ Program. 2012; Dec.8(1):529-535.）

　　Perioperative management of patients on chronic antithrombotic therapy.

　　Ortel TL

　　1Hemostasis and Thrombosis Center, Duke University Medical Center, Durham, NC.

　　Hematology Am Soc Hematol Educ Program. 2012;2012:529-35. doi: 10.1182/asheducation-2012.1.529.

　　Abstract

　　Perioperative management of antithrombotic therapy is a situation that occurs frequently and requires consideration of the patient, the procedure, and an expanding array of anticoagulant and antiplatelet agents. Preoperative assessment must address each patient's risk for thromboembolic events balanced against the risk for perioperative bleeding. Procedures can be separated into those with a low bleeding risk, which generally do not require complete reversal of the antithrombotic therapy, and those associated with an intermediate or high bleeding risk. For patients who are receiving warfarin who need interruption of the anticoagulant, consideration must be given to whether simply withholding the anticoagulant is the optimal approach or whether a perioperative "bridge" with an alternative agent, typically a low-molecular-weight heparin, should be used. The new oral anticoagulants dabigatran and rivaroxaban have shorter effective half-lives, but they introduce other concerns for perioperative management, including prolonged drug effect in patients with renal insufficiency, limited experience with clinical laboratory testing to confirm lack of residual anticoagulant effect, and lack of a reversal agent. Antiplatelet agents must also be considered in the perioperative setting, with particular consideration given to the potential risk for thrombotic complications in patients with coronary artery stents who have antiplatelet therapy withheld.