低分子肝素在PCI术后围手术期桥接治疗中的争议与进展

Low Molecular Weight Heparin Bridging Therapy After PCI: Controversies and Advances

关键词:  冠状动脉介入治疗  低分子肝素  双联抗血小板治疗  桥接治疗  围手术期

Key words:  percutaneous coronary intervention  low molecular weight heparin  dual antiplatelet therapy  bridging therapy  perioperative period

摘要:

低分子肝素(Low Molecular Weight Heparin,LMWH)在冠状动脉介入治疗(Percutaneous Coronary Intervention,PCI)术后患者非心脏手术围手术期作为双联抗血小板治疗桥接方案目前依然存在争议。本文通过综述国内外指南共识、临床试验及机制研究,分析LMWH在平衡血栓与出血风险中的作用。目前国际指南多不推荐LMWH用于抗血小板药物的桥接治疗,而国内专家共识对该问题存在分歧；临床研究显示,LMWH用于围手术期的获益与风险可能与PCI术后至非心脏手术的时间间隔有显著相关性；而机制研究提示,PCI术后早期支架尚未内皮化时,LMWH替代抗血小板药物可能无法完全抑制血小板大量聚集引起的血栓进展。因此,建议根据PCI术后时间间隔、出血及血栓风险等因素个体化决策,高血栓风险期推荐首选短效抗血小板药物维持血小板抑制作用,慎重考虑LMWH作为该阶段的桥接方案。

Abstract:

The use of low molecular weight heparin (LMWH) as a bridging therapy for dual antiplatelet therapy (DAPT) in patients undergoing non-cardiac surgery after percutaneous coronary intervention (PCI) remains controversial. This review summarizes guidelines, clinical trials, and mechanistic studies from domestic and international sources to analyze the role of LMWH in balancing thrombotic and bleeding risks. Current international guidelines generally do not recommend LMWH for bridging antiplatelet therapy, while Chinese expert consensus documents reflect divergent opinions on this issue. Clinical studies indicate that the benefits and risks of LMWH in the perioperative period may be significantly associated with the time interval between PCI and non-cardiac surgery. Mechanistic evidence suggests that in the early post-PCI phase, LMWH may inadequately suppress thrombosis driven by intense platelet aggregation when stent endothelialization is incomplete. Therefore, individualized decision-making based on the post-PCI time interval, thrombotic risk, and bleeding risk is recommended. During high thrombotic risk periods, short-acting antiplatelet agents should be prioritized to maintain platelet inhibition, and LMWH as a bridging strategy in this context should be considered with caution.