Renato D. Lopes教授强调,没有一种方案能适合于每个人。我们要掌握的是判断标准和标准化的方法,而不是单纯考虑抗凝药物的类型[4]。
图8 出血后恢复口服抗凝剂的决策框架
三
总结 直接口服抗凝药代表了我们治疗血栓患者或有血栓风险患者的一个进步,与华法林相比,在大型随机对照试验中,直接口服抗凝药物的致死性出血风险更低。但抗凝治疗依然存在出血的风险,我们能做的首先就是尽量减少出血的发生! 如果出血事件已经出现,首先需要及早止血,如果出现致死性的大出血,要积极给予逆转抗凝的治疗。考虑到患者的原发病,重启抗凝十分重要,何时及如何重启抗凝是一个问题,要牢记使用标准化的方法而不是考虑抗凝剂的类型;在发生大出血时应及早进行介入治疗以争取更多时间。 最重要的是,不要恐慌,支持性的对症治疗是最好的选择! 参考资料:[1]Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. doi: 10.1093/eurheartj/ehaa612. Erratum in: Eur Heart J. 2021 Feb 1;42(5):507. Erratum in: Eur Heart J. 2021 Feb 1;42(5):546-547. Erratum in: Eur Heart J. 2021 Oct 21;42(40):4194. PMID: 32860505.[2]Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H; External reviewers. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace. 2021 Oct 9;23(10):1612-1676. doi: 10.1093/europace/euab065. Erratum in: Europace. 2021 Jun 28;: PMID: 33895845.[3]Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2015 Oct;17(10):1467-507. doi: 10.1093/europace/euv309. Epub 2015 Aug 31. PMID: 26324838.[4]Xu Y, Siegal DM. Anticoagulant-associated gastrointestinal bleeding: Framework for decisions about whether, when and how to resume anticoagulants. J Thromb Haemost. 2021 Oct;19(10):2383-2393. doi: 10.1111/jth.15466. Epub 2021 Jul 29. PMID: 34273241.