心脏瓣膜置换术患者低分子肝素抗凝桥围手术期国际标准化比值测定

IF 3.4 3区医学 Q2 HEMATOLOGY

Research and Practice in Thrombosis and Haemostasis Pub Date : 2024-11-01 DOI:10.1016/j.rpth.2024.102616

Liza Rijvers , Sanna R. Rijpma , Herbert B. van Wetten , Yvonne M.C. Henskens , An K. Stroobants

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引用次数: 0

摘要

背景：抗凝患者的外科手术需要特别注意，因为出血风险增加。高危患者术前中断抗凝治疗往往是必要的。桥接抗凝与低分子肝素（LMWH）可将血栓栓塞风险降至最低，但其对国际标准化比率（INR）测量的影响尚未得到很好的确定，需要仔细监测和个体评估。目的探讨肝素桥接对抗凝患者维生素K拮抗剂（VKA） INR测定的影响及体外尖峰实验。方法对38例VKA抗凝患者行瓣膜置换术，术后恢复VKA后多个时间点采用2项血浆INR测定和1项全血护理点INR测定。此外，比较了正常和vka治疗个体血浆中的INR水平，在4次INR检测中有7次低分子肝素或未分离肝素（UFH）浓度升高。结果在低分子肝素桥接抗凝患者中，在VKA重新启动后3天内，使用hemsil recombbiplastin和Coaguchek获得的INR结果显著高于使用STA Hepato presst获得的INR结果。在将不同浓度的低分子肝素或UFH注入混合血浆后，只有STA Hepato Prest检测在治疗范围（1.0-2.0国际单位/mL）内对VKA和正常血浆的INR测量没有干扰。所有其他检测都显示出明显的干扰，其中血小板相关性S检测是肝素最敏感的检测。结论在术后接受低分子肝素桥接的患者重新启动VKA后72小时内，INR方法之间存在差异。使用低分子肝素和UFH进行的体外实验表明，即使在低于供应商规定的肝素干扰限值的浓度下，肝素也会干扰多种INR方法。

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International normalized ratio measurement during perioperative anticoagulation bridging with low-molecular-weight heparin in patients undergoing heart valve replacement surgery

Background

Surgical procedures in anticoagulated patients require specific attention due to increased bleeding risk. Preoperative anticoagulation interruption in high-risk patients is often necessary. Bridging anticoagulation with low-molecular-weight heparin (LMWH) minimizes thromboembolic risk, but its effect on international normalized ratio (INR) measurement is not well established, necessitating careful monitoring and individual assessment.

Objectives

To investigate the effect of heparin bridging on INR measurements in anticoagulated patients on vitamin K antagonist (VKA) and in in vitro spiking experiments.

Methods

Thirty-eight anticoagulated patients on VKA undergoing valve replacement surgery were studied using 2 plasma-based INR assays and 1 whole blood point-of-care INR method at multiple time points after postoperatively resuming VKA. In addition, INR levels in pooled plasma of both normal and VKA-treated individuals were compared, with 7 spiked concentrations of LMWH or unfractionated heparin (UFH) in 4 INR assays.

Results

In LMWH-bridged anticoagulated patients, the INR results obtained with HemosIL RecombiPlasTin and point-of-care Coaguchek were significantly higher than those obtained with STA Hepato Prest within 3 days after restart of VKA. After spiking LMWH or UFH in various concentrations into pooled plasma, only the STA Hepato Prest assay showed no interference in INR measurement within the therapeutic range (1.0-2.0 international units/mL) in both VKA and normal plasma. All other assays showed substantial interference, with the Thromborel S assay being the most heparin-sensitive assay.

Conclusion

Differences between INR methods are seen within 72 hours after restarting VKA in postoperative patients who receive LMWH bridging. In vitro experiments using LMWH and UFH show the interference of heparin in multiple INR methods, even with concentrations below the suppliers’ stated heparin interference limits.

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