目的:提高对肝素诱导的血小板减少症(Heparin-induced thrombocytopenia, HIT)的识别与重视,减少误诊。方法:对1例肝素类药物诱导HIT患者临床资料进行回顾性分析,复习相关文献。结果:患者因急性冠脉综合症行主动脉内球囊反搏(Intra-aortic balloon pump, IABP)辅助冠脉搭桥术(Coronary artery bypass grafting, CABG),围术期应用肝素类药物抗凝治疗后出现血小板急剧减少并有血栓形成,根据4Ts评分高度怀疑为II型HIT,停用一切肝素类药物,采用新型口服抗凝药物利伐沙班替代抗凝治疗。结论:CABG术后患者有发生桥血管血栓形成风险,同时HIT也会导致血管内血栓形成,二者大大增加了血栓形成风险,对CABG术后使用肝素类药物出现血小板减少患者需高度警惕HIT,以免发生不良事件。 Objective: To improve the timely recognition and attention of Heparin-induced Thrombocytopenia (HIT) and reduce misdiagnosis. Methods: The clinical data of a patient with one heparin-induced HIT was analyzed retrospectively, and refer to the relevant literature for analysis. Results: The patient with Acute Coronary Syndrome (ACS) was treated with Intra-aortic Balloon Pump (IABP) assisted Coronary Artery Bypass Grafting (CABG). According to the 4Ts score highly suspected to be type II HIT, all heparin drugs were stopped and a new oral anticoagulant rivaroxaban was used instead of anticoagulant therapy. Conclusion: CABG postoperative patients have the risk of bridge thrombosis, and HIT can also lead to intravascular thrombosis. The coexistence of the two greatly increases the risk of thrombosis. Therefore, patients with thrombocytopenia after CABG use of heparin drugs should be highly vigilant HIT, so as to avoid adverse events.
目的:提高对肝素诱导的血小板减少症(Heparin-induced thrombocytopenia, HIT)的识别与重视,减少误诊。方法:对1例肝素类药物诱导HIT患者临床资料进行回顾性分析,复习相关文献。结果:患者因急性冠脉综合症行主动脉内球囊反搏(Intra-aortic balloon pump, IABP)辅助冠脉搭桥术(Coronary artery bypass grafting, CABG),围术期应用肝素类药物抗凝治疗后出现血小板急剧减少并有血栓形成,根据4Ts评分高度怀疑为II型HIT,停用一切肝素类药物,采用新型口服抗凝药物利伐沙班替代抗凝治疗。结论:CABG术后患者有发生桥血管血栓形成风险,同时HIT也会导致血管内血栓形成,二者大大增加了血栓形成风险,对CABG术后使用肝素类药物出现血小板减少患者需高度警惕HIT,以免发生不良事件。
肝素,血小板减少,血栓形成,IABP,CABG
Li Gong1*, Hongyan Dai2, Chunhua Huang1#
1School of Clinical Medicine, Weifang Medical University, Weifang Shandong
2Cardiology Department of Qingdao Municipal Hospital, Qingdao Shandong
Received: Oct. 26th, 2021; accepted: Nov. 23rd, 2021; published: Nov. 30th, 2021
Objective: To improve the timely recognition and attention of Heparin-induced Thrombocytopenia (HIT) and reduce misdiagnosis. Methods: The clinical data of a patient with one heparin-induced HIT was analyzed retrospectively, and refer to the relevant literature for analysis. Results: The patient with Acute Coronary Syndrome (ACS) was treated with Intra-aortic Balloon Pump (IABP) assisted Coronary Artery Bypass Grafting (CABG). According to the 4Ts score highly suspected to be type II HIT, all heparin drugs were stopped and a new oral anticoagulant rivaroxaban was used instead of anticoagulant therapy. Conclusion: CABG postoperative patients have the risk of bridge thrombosis, and HIT can also lead to intravascular thrombosis. The coexistence of the two greatly increases the risk of thrombosis. Therefore, patients with thrombocytopenia after CABG use of heparin drugs should be highly vigilant HIT, so as to avoid adverse events.
Keywords:Heparin, Thrombocytopenia, Thrombosis, IABP, CABG
Copyright © 2021 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
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主动脉内球囊反搏是临床上应用最广泛的短期机械辅助循环方法之一,主要应用于急性冠脉综合症患者,可明显降低围术期风险,辅助冠脉搭桥手术的进行 [
患者,男,82岁,因“发作性胸痛、胸闷半年,加重1月”于2020-07-20入院,既往高血压、糖尿病20余年。入院查体:T 36.2℃,R 17次/分,P 94次/分,BP 143/69 mmHg,急性窘迫面容,端坐呼吸,双肺呼吸音低,双肺底可闻及湿性罗音,心率150次/分,心律绝对不齐,第一心音强弱不等,无杂音,双下肢凹陷性水肿。入院心电图:1、心房颤动;2、V1、V2 R波递增不良;3、V6、V7 ST-T段压低,T波双向倒置。心肌标志物:CK-MB 111.09 ng/ml,cTnI 0.587 ng/ml,NT-ProBNP 5144.28 pg/ml;PT 13.10 s,APTT 31.70 s,D-二聚体0.94 ug/ml。入院诊断为:1、急性冠脉综合征;2、急性左心衰;3、心房颤动。给予阿司匹林、替格瑞洛抗血小板治疗,降压、利尿、止痛、吸氧等对症支持治疗,并紧急行冠脉造影检查,结果提示冠脉多支血管狭窄、闭塞。植入IABP辅助冠脉搭桥治疗,术中动脉内注射肝素5000 iu,术后转入心外CCU,继续口服阿司匹林、替格瑞洛,先后联合肝素钠、依诺肝素钠、那曲肝素钙抗凝治疗。07-23超声心动图:左室大,左室壁节段性运动异常,左室收缩功能减低;EF:29%。07-31查PLT 42.00 × 10^9/L,停用阿司匹林,其余治疗未变,08-03复查PLT 12 × 10^9/L,血小板下降至危急值,有出血倾向,立即输血小板2 iu并停用肝素类抗凝药物。08-04复查PLT 59 × 10^9/L,患者心房颤动,搭桥术后呈高凝状态,有发生血栓栓塞高风险,给予那曲肝素、肝素钠注射液治疗2天,血小板再次出现下降,行床旁心脏超声心动图:右心内实性占位,考虑右房血栓形成可能,停用肝素钠,改用为华法林5 mg qd、那曲肝素4100 iu皮下注射q12h,降低出血风险。08-07转入心内CCU,行下肢深静脉超声:左侧下肢深静脉血栓形成,查PLT 32.00 × 10^9/L,INR 11.34,PT 88.00 S,APTT 63.70 S,FDP 48.56 ug/ml,D-二聚体15.12 ug/ml。患者凝血指标异常,出血风险高,停用华法林及那曲肝素,紧急输冷沉淀8U补充凝血因子,并予维生素K拮抗华法林,当日复查凝血常规PT 46.00 S,INR 4.95,凝血指标较前明显改善。患者血小板减少考虑HIT可能性大,患者右房血栓合并下肢静脉血栓,随时有脱落肺栓塞的可能,给予阿加曲班抗凝治疗。08-13查PLT 81 × 10^9/L,INR 2.20,PT 24.40 S,APTT 48.50 S,凝血指标下降至安全范围,停用阿加曲班,给予小剂量华法林治疗。08-14患者复查心脏超声提示右房血栓消失,复查下肢静脉超声仍有双下肢深静脉血栓,多次复查凝血指标INR均高于安全范围,停用华法林并给予维生素K1拮抗,患者下肢静脉血栓形成有抗凝指征,待INR稳定在安全范围后给予新型口服抗凝药物。08-20查INR 1.81,给予利伐沙班口服抗凝治疗。经上述治疗后血小板恢复至正常。08-24查PLT 129 × 10^9/L,PT 19.80 S,APTT 44.60 S,患者凝血指标、血小板恢复正常(图1示病人住院期间血小板计数变化情况),准予出院。出院后继续服用利伐沙班10 mg bid,定期随访血常规、凝血常规、超声心动图、下肢静脉超声未见异常。
图1. 病人住院期间血小板计数变化情况
HIT分为I型和II型,I型HIT为良性过程,血小板轻微下降,不会引起血栓或出血事件,不需停药和特殊处理。II型HIT与免疫相关,具有很高的血栓形成风险 [
本例患者行IABP辅助冠脉搭桥术,围术期给予抗血小板、抗凝治疗。入院时查血常规未见血小板下降,查体无全身性紫癜、严重感染等表现,排除入院前血小板减少可能。因此血小板减少考虑与入院后使用药物及手术治疗相关。患者围术期用药先后有抗血小板药物阿司匹林、替格瑞洛、氯吡格雷及抗凝药物肝素及低分子肝素。入院后第10天开始出现血小板减少,停用阿司匹林与氯吡格雷后血小板仍处于下降趋势,可排除抗血小板药物导致的血小板减少症。患者入院后应用IABP辅助治疗7天,撤机3天后出现血小板减少。IABP球囊会机械破坏循环中的血小板导致血小板减少,以血小板 < 150 × 109/L为诊断标准,通常血小板减少程度较轻,大部分患者置入IABP后血小板开始下降,第3~4 d达到稳定,IABP拔除2~3 d后恢复正常水平 [
本例患者在治疗上的不足:1) HIT是一种高凝状态,可加重血栓栓塞形成风险 [
冠脉搭桥术后患者有发生血栓形成风险 [
龚 莉,戴红艳,黄春华. IABP辅助冠脉搭桥术后肝素抗凝治疗引起HIT一例A Case of HIT Caused by Heparin Anticoagulant Therapy after IABP Assisted Coronary Artery Bypass Grafting[J]. 临床医学进展, 2021, 11(11): 5531-5534. https://doi.org/10.12677/ACM.2021.1111819