脑出血后重启抗凝治疗的研究进展

doi:10.3969/j.issn.1673-5765.2020.01.007

摘要/Abstract

摘要：

抗凝治疗已广泛用于心房颤动和（或）机械性心脏瓣膜患者以预防血栓栓塞事件，尤其是预防缺血性卒中的发生。然而，脑出血后是否应继续抗凝治疗及何时重启抗凝治疗仍是临床未解的难题。虽然目前已有数项大样本观察性研究和Meta分析提示脑出血后重启抗凝治疗可降低血栓栓塞并发症且没有明显增加出血并发症，但是尚缺乏随机对照试验进一步证实。因此，目前在缺乏指导临床决策的高质量临床研究证据的情况下，临床实践中应权衡患者血栓栓塞事件风险和脑出血复发风险进行个体化处理。

文章导读： 脑出血后是否应继续抗凝治疗及何时重启抗凝治疗是亟待解决的临床问题。目前缺乏高质量随机对照试验证据，应权衡患者血栓栓塞事件风险和脑出血复发风险进行个体化处理。

关键词: 脑出血; 抗凝; 华法林; 非维生素K口服抗凝剂

Abstract:

Anticoagulation is currently recommended and commonly used in patients with atrial fibrillation and/or mechanical prosthetic heart valves to prevent thromboembolism events, especially stroke. However, the decision-making about whether and when to resume anticoagulant after intracerebral hemorrhage (ICH) is still an unsolved problem due to lacking randomized controlled trials. Several large-scale observational studies and meta analysis showed that anticoagulant resumption after ICH decreased thromboembolic complications without increasing hemorrhagic complications. Given the lack of high-quality evidence, clinicians should carefully balance the risk of thromboembolism and recurrent ICH in individual patients.

Key words: Intracerebral Hemorrhage; Anticoagulation; Warfarin; Non-vitamin K oralb anticoagulant

吴炯星，王德任. 脑出血后重启抗凝治疗的研究进展[J]. 中国卒中杂志, 2020, 15(01): 46-50.

WU Jiong-Xing, WANG De-Ren. Advances in Anticoagulant Resumption after Intracerebral Hemorrhage[J]. Chinese Journal of Stroke, 2020, 15(01): 46-50.

参考文献

[1] 中华医学会神经病学分会，中华医学会神经病学分

会脑血管病学组. 中国脑出血诊治指南（2014）[J]. 中

华神经科杂志，2015，48（6）：435-444.

[2] LIOTTA E M，PRABHAKARAN S. Warfarinassociated

intracerebral hemorrhage is increasing

in prevalence in the United States[J]. J Stroke

Cerebrovasc Dis，2013，22（7）：1151-1155.

[3] HEMPHILL J C 3rd，GREENBERG S

M，ANDERSON C S，et al. Guidelines for

the management of spontaneous intracerebral

hemorrhage：a guideline for healthcare professionals

from the American Heart Association/American

Stroke Association[J]. Stroke，2015，46（7）：2032-

2060.

[4] KURAMATSU J B，SEMBILL J A，GERNER S

T，et al. Management of therapeutic anticoagulation

in patients with intracerebral haemorrhage and

mechanical heart valves[J]. Eur Heart J，2018，39

（19）：1709-1723.

[5] KURAMATSU J B，GERNER S T，SCHELLINGER

P D，et al. Anticoagulant reversal，blood pressure

levels，and anticoagulant resumption in patients with

anticoagulation-related intracerebral hemorrhage[J].

JAMA，2015，313（8）：824-836.

[6] OGATA T，YASAKA M，WAKUGAWA Y，et al.

Deep venous thrombosis after acute intracerebral

hemorrhage[J]. J Neurol Sci，2008，272（1-2）：83-

86.

[7] COUNSELL C，BOONYAKARNKUL S，DENNIS

M，et al. Primary intracerebral haemorrhage in

the Oxfordshire Community Stroke Project[J].

Cerebrovasc Dis，1995，5（1）：26-34.

[8] BAILEY R D，HART R G，BENAVENTE O，et al.

Recurrent brain hemorrhage is more frequent than

ischemic stroke after intracranial hemorrhage[J].

Neurology，2001，56（6）：773-777.

[9] POON M T，FONVILLE A F，AL-SHAHI

SALMAN R. Long-term prognosis after

intracerebral haemorrhage：systematic review and

meta-analysis.[J]. J Neurol Neurosurg Psychiatry，

2014，85（6）：660-667.

[10] PERRY L A，BERGE E，BOWDITCH J，et

al. Antithrombotic treatment after stroke due

to intracerebral haemorrhage[J/OL]. Cochrane

Database Syst Rev，2017，5：CD012144. https：//doi.org/10.1002/14651858.CD012144.pub2.

[11] BIFFI A，KURAMATSU J B，LEASURE A，et al.

Oral anticoagulation and functional outcome after

intracerebral hemorrhage[J]. Ann Neurol，2017，82

（5）：755-765.

[12] RUFF C T，GIUGLIANO R P，BRAUNWALD E，et

al. Comparison of the efficacy and safety of new oral

anticoagulants with warfarin in patients with atrial

fibrillation：a meta-analysis of randomised trials[J].

Lancet，2014，383（9921）：955-962.

[13] CONNOLLY S J，EZEKOWITZ M D，YUSUF S，et

al. Dabigatran versus warfarin in patients with atrial

fibrillation[J]. N Engl J Med，2009，361（12）：1139-

1151.

[14] PATEL M R，MAHAFFEY K W，GARG J，et al.

Rivaroxaban versus warfarin in nonvalvular atrial

fibrillation[J]. N Engl J Med，2011，365（10）：883-

891.

[15] GRANGER C B，ALEXANDER J H，MCMURRAY

J J，et al. Apixaban versus warfarin in patients with

atrial fibrillation[J]. N Engl J Med，2011，365（11）：

981-992.

[16] WILSON D，SEIFFGE D J，TRAENKA C，et al.

Outcome of intracerebral hemorrhage associated

with different oral anticoagulants.[J]. Neurology，

2017，88（18）：1693-1700.

[17] INOHARA T，XIAN Y，LIANG L，et al.

Association of intracerebral hemorrhage among

patients taking non-vitamin K antagonist vs vitamin

K antagonist oral anticoagulants with in-hospital

mortality[J]. JAMA，2018，319（5）：463-473.

[18] HEIDBUCHEL H，VERHAMME P，ALINGS M，

et al. Updated European Heart Rhythm Association

Practical Guide on the use of non-vitamin K

antagonist anticoagulants in patients with nonvalvular

atrial fibrillation[J]. Europace，2015，17

（10）：1467-1507.

[19] STEFFEL J，VERHAMME P，POTPARA T S，et

al. The 2018 European Heart Rhythm Association

Practical Guide on the use of non-vitamin K

antagonist oral anticoagulants in patients with atrial

fibrillation[J]. Eur Heart J，2018，39（16）：1330-

1393.

[20] KURAMATSU J B，HUTTNER H B. Management

of oral anticoagulation after intracerebral

hemorrhage[J]. Int J Stroke，2019，14（3）：238-246.