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Volume 40 Issue 4
Jul.  2022
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LI Ying, CAO Ailin, BAO Leilei, WANG Zhankun, QIAN Jiao. Perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation: a case report and literature review[J]. Journal of Pharmaceutical Practice and Service, 2022, 40(4): 372-373, 386. doi: 10.12206/j.issn.1006-0111.202103074
Citation: LI Ying, CAO Ailin, BAO Leilei, WANG Zhankun, QIAN Jiao. Perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation: a case report and literature review[J]. Journal of Pharmaceutical Practice and Service, 2022, 40(4): 372-373, 386. doi: 10.12206/j.issn.1006-0111.202103074

Perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation: a case report and literature review

doi: 10.12206/j.issn.1006-0111.202103074
  • Received Date: 2021-03-25
  • Rev Recd Date: 2021-06-09
  • Available Online: 2022-07-27
  • Publish Date: 2022-07-25
  •   Objective  To explore the strategies of perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation.   Methods  The antithrombotic therapy in one patient undergoing revision total hip arthroplasty after coronary stent implantation was analyzed with the review of related literatures.   Results  The patient developed non-ST segment elevated myocardial infarction due to the stop of aspirin three days before operation and no low molecular weight heparin was used. The antithrombotic treatment and prevention of venous thromboembolism were analyzed.   Conclusion  Antithrombotic therapy should be selected reasonably in patients undergoing revision total hip arthroplasty after coronary stent implantation.
  • [1] 周宗科, 翁习生, 曲铁兵, 等. 中国髋、膝关节置换术加速康复: 围术期管理策略专家共识[J]. 中华骨与关节外科杂志, 2016, 9(1):1-9. doi:  10.3969/j.issn.2095-9985.2016.01.001
    [2] KUMAR A, TSAI W C, TAN T S, et al. Risk of post-TKA acute myocardial infarction in patients with a history of myocardial infarction or coronary stent[J]. Clin Orthop Relat Res,2016,474(2):479-486. doi:  10.1007/s11999-015-4616-z
    [3] 中华医学会心血管病学分会介入心脏病学组, 中国医师协会心血管内科医师分会血栓防治专业委员会, 中华心血管病杂志编辑委员会. 中国经皮冠状动脉介入治疗指南(2016)[J]. 中华心血管病杂志, 2016, 44(5):382-400. doi:  10.3760/cma.j.issn.0253-3758.2016.05.006
    [4] YANG Z, NI J, LONG Z, et al. Is hip fracture surgery safe for patients on antiplatelet drugs and is it necessary to delay surgery? A systematic review and meta-analysis[J]. J Orthop Surg Res,2020,15(1):105. doi:  10.1186/s13018-020-01624-7
    [5] LIPPI G, CERVELLIN G. Aspirin for thromboprophylaxis in major orthopedic surgery: old drug, new tricks? Acta Biomed,2018,89(1):31-33.
    [6] WANG X, CHEN X, SUN W, et al. Very late stent thrombosis in drug-eluting stents new observations and clinical implications[J]. Cardiol Rev,2019,27(6):279-285. doi:  10.1097/CRD.0000000000000283
    [7] LEE H L, CHIU K Y, YIU K H, et al. Perioperative antithrombotic management in joint replacement surgeries[J]. Hong Kong Med J,2013,19(6):531-538.
    [8] 中华医学会骨科学分会. 中国骨科大手术静脉血栓栓塞症预防指南[J]. 中华骨科杂志, 2016, 36(2):65-71. doi:  10.3760/cma.j.issn.0253-2352.2016.02.001
    [9] 中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. 非ST段抬高型急性冠状动脉综合征诊断和治疗指南(2016)[J]. 中华心血管病杂志, 2017, 45(5):359-376. doi:  10.3760/cma.j.issn.0253-3758.2017.05.003
    [10] 国家卫生计生委合理用药专家委员会, 中国药师协会. 冠心病合理用药指南(第2版)[J]. 中国医学前沿杂志(电子版), 2018, 10(6):1-130.
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Perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation: a case report and literature review

doi: 10.12206/j.issn.1006-0111.202103074

Abstract:   Objective  To explore the strategies of perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation.   Methods  The antithrombotic therapy in one patient undergoing revision total hip arthroplasty after coronary stent implantation was analyzed with the review of related literatures.   Results  The patient developed non-ST segment elevated myocardial infarction due to the stop of aspirin three days before operation and no low molecular weight heparin was used. The antithrombotic treatment and prevention of venous thromboembolism were analyzed.   Conclusion  Antithrombotic therapy should be selected reasonably in patients undergoing revision total hip arthroplasty after coronary stent implantation.

LI Ying, CAO Ailin, BAO Leilei, WANG Zhankun, QIAN Jiao. Perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation: a case report and literature review[J]. Journal of Pharmaceutical Practice and Service, 2022, 40(4): 372-373, 386. doi: 10.12206/j.issn.1006-0111.202103074
Citation: LI Ying, CAO Ailin, BAO Leilei, WANG Zhankun, QIAN Jiao. Perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation: a case report and literature review[J]. Journal of Pharmaceutical Practice and Service, 2022, 40(4): 372-373, 386. doi: 10.12206/j.issn.1006-0111.202103074
  • 髋关节置换术及髋关节翻修术后患者有发生静脉血栓栓塞症(VTE)的可能[1]。这类患者中有一些既往行冠脉支架植入术需常规口服抗栓药的患者,持续抗血栓治疗可能会导致围术期出血风险增加,而停药又可能导致急性冠状动脉综合征(ACS)和/或动脉血栓栓塞(ATE)发生[2],因此,合适的抗栓方案成为治疗的关键。笔者分析1例冠状动脉支架植入术后髋关节翻修术患者的抗栓治疗策略,并进行文献复习,以期为临床提供参考。

    • 患者,男,63岁,因“左全髋置换术后19年,疼痛伴无法行走7个多月”入住骨关节科。患者于18月前行冠状动脉支架植入术,高血压病史、糖尿病病史多年,入院前长期服用阿司匹林肠溶片及降压、降糖药。入院诊断:左全髋关节置换术后假体松动;有冠状动脉支架植入术史;高血压;糖尿病。

      患者入院后予阿托伐他汀钙片20 mg qn;替米沙坦氢氯噻嗪胶囊40 mg qd;格列齐特缓释片30 mg qd;伏格列波糖片0.3 mg tid,3 d后在腰麻下行左侧人工髋关节翻修术。术后红细胞计数3.83×1012/L,血小板计数141×109/L,血红蛋白108 g/L,D-二聚体4.96μg/ml,凝血酶原时间15.8 s。术后17 h患者出现胸闷不适,诊断为急性非ST段抬高性心肌梗死(NSTEMI)。转入心内科给予阿司匹林肠溶片100 mg qd+硫酸氢氯吡格雷片75 mg qd 口服;依诺肝素钠注射液4000 U bid 皮下注射,治疗后患者心肌梗死缓解。术后6 d红细胞计数2.40×1012/L、血小板计数237×109/L、血红蛋白66 g/L,患者进行性红细胞下降,术后8、9、10 d分别输注红细胞悬液2 U。停用硫酸氢氯吡格雷片,改为单用阿司匹林肠溶片100 mg qd 口服;停用依诺肝素钠注射液,改为利伐沙班片15 mg qd 口服。术后10 d红细胞计数4.90×1012/L,血小板计数276×109/L,血红蛋白139 g/L。患者病情平稳,予以出院口服药物治疗。

    • 冠状动脉支架植入术后患者需口服抗血小板药用于ATE的二级预防[3],研究表明阿司匹林会增加围术期出血的风险,但并不会导致发病率和病死率增加[4-5],而围术期停用阿司匹林可使ATE风险增高[6],对于服用阿司匹林进行ATE二级预防的高危患者建议围术期继续应用[7]。另一方面,对于已服用阿司匹林的患者应根据需要调整剂量或给予额外的低分子肝素(LMWH)[7],指南建议对于长期服用阿司匹林或氯吡格雷的患者应于骨科大手术术前5 d停用阿司匹林,术前7 d停用氯吡格雷,停药期间桥接应用LMWH[8]。该患者冠状动脉支架植入术后一直服用阿司匹林,临床药师结合以上指南及文献认为其髋关节翻修术围术期继续应用阿司匹林,或术前5 d停用阿司匹林,停药期间桥接应用LMWH,术后24 h若无活动性出血恢复阿司匹林。而该患者入院后即停用阿司匹林,3 d后行髋关节翻修术,期间亦未用LMWH进行桥接抗凝,导致抗栓治疗不足,患者术后出现了NSTEMI。

    • 髋关节翻修术后患者易发生ATE风险,ACS是主要风险之一。该患者髋关节翻修术后出现NSTEMI,为ACS常见类型,应口服抗血小板药,合用抗凝药可产生更强大的抗栓效应[9-10]。该患者抗栓治疗方案为阿司匹林肠溶片100 mg qd和硫酸氢氯吡格雷片75 mg qd双联抗血小板,联合依诺肝素钠注射液4000 U bid抗凝治疗。经治疗患者心肌梗死缓解,术后6 d患者出现进行性红细胞计数下降,考虑抗栓过度。根据指南[9],对NSTEMI急性期后有低出血风险的患者可停用肠外抗凝药,口服阿司匹林、氯吡格雷或利伐沙班治疗。临床药师协助医师停用依诺肝素钠注射液,改为利伐沙班片抗凝治疗;停双联抗血小板治疗,改为单用阿司匹林肠溶片;同时输注红细胞悬液。患者应用抗血小板药物及抗凝药物,出血风险较大,应谨慎观察是否有鼻衄、牙龈出血、胃肠道出血等出血体征;并关注血红蛋白等实验室检查结果以发现隐匿性出血。临床药师密切监测患者血栓及出血风险,至出院时患者病情平稳。嘱患者出院后如出现胸闷、气急、胸痛、消化道出血等不适及时就诊。

    • VTE是髋关节翻修术后有较高发生率的并发症之一,重点在预防深静脉血栓(DVT)的形成,预防药物主要有LMWH、利伐沙班、阿哌沙班和磺达肝癸钠[7]。对于已服用阿司匹林或氯吡格雷的患者骨科大手术后应加用LMWH预防VTE[8],预防时间至少为10~14 d,髋关节置换术后患者药物预防时间建议延长至35 d[7]。该患者术后皮下注射常规剂量LMWH依诺肝素,后改为口服利伐沙班片,在院期间未发生VTE;出院带药利伐沙班片继续口服预防VTE,建议用至髋关节翻修术后35 d。嘱患者出院后注意是否有肢体肿胀、疼痛,呼吸困难等可能发生VTE的症状出现;同时留意是否有血便、黑便,血尿等药物所致出血不良反应,如有相应情况及时就医。

    • 冠状动脉支架植入术后患者行髋关节翻修术的围术期管理具有特殊性和复杂性,抗栓治疗应平衡血栓形成与出血的风险,合理选择抗栓治疗方案,以降低髋关节翻修术围术期ACS、VTE发生率及出血风险。

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