合并心房颤动的大面积脑梗死患者预防 下肢深静脉血栓的最佳方案及抗凝 启动时机的临床研究

Optimization of Prophylactic Regimen and Timing of Anticoagulation Initiation for Lower Extremity Deep Venous Thrombosis in Patients with Large Hemispheric Infarction Complicated by Atrial Fibrillation

摘要: 目的：探讨合并心房颤动(AF)的大面积脑梗死(LHI)患者下肢深静脉血栓(DVT)的最佳预防方案，分析不同抗凝启动时机的安全性与有效性，为临床制定个体化血栓预防策略提供循证依据。方法：采用回顾性队列研究，纳入2018年1月至2025年12月内蒙古自治区人民医院住院的合并AF的LHI患者。根据住院期间主要DVT预防策略及抗凝启动时间进行分组。以双下肢静脉彩色多普勒超声证实的DVT形成为有效性结局，以颅内出血、消化道出血等任意出血事件为安全性结局。采用Firth校正的多因素logistic回归模型分析不同策略与结局事件的关联，并通过Kaplan-Meier法描述出血事件的累积风险。结果：91例患者中17例发生DVT，发生率为18.79%。单因素分析显示不同预防方案组DVT发生率差异有统计学意义(P < 0.001)；Firth校正的多因素logistic回归分析显示，以单独一种血小板 + 小剂量肝素组为参照，单独机械预防组(调整后OR = 22.99，95% CI: 4.16~244.50，P < 0.001)、单独一种抗血小板组(OR = 7.90, 95% CI: 1.59~78.40, P = 0.009) DVT发生风险显著升高，与单独两种抗血小板组、单独抗凝组无显著差异(P > 0.05)；各方案组任意出血事件发生率无显著差异(均P > 0.05)。不启动抗凝、1~2 d或3~7 d启动抗凝这三组对DVT的发生率差异具有统计学意义(P < 0.001)；不启动抗凝、1~2 d或3~7 d启动抗凝对任意出血事件颅内出血、消化道出血)三组比较无显著统计学差异(P > 0.05)，且累积风险均无显著差异(均P > 0.05)。结论：一种抗血小板药物联合小剂量肝素的预防方案在降低合并AF的LHI患者DVT发生风险方面具有更优的风险获益比；入院1~2 d启动抗凝治疗可能安全且有效。

Abstract: Objective: To explore the optimal prophylactic regimen for lower extremity deep venous thrombosis (DVT) in patients with large hemispheric infarction (LHI) complicated by atrial fibrillation (AF), and to analyze the safety and efficacy of different anticoagulation initiation timings, so as to provide evidence-based basis for clinical individualized thrombosis prevention strategies. Methods: This study was designed as a retrospective cohort analysis including patients with large hemispheric infarction (LHI) complicated by atrial fibrillation (AF) who were admitted to the People’s Hospital of Inner Mongolia Autonomous Region between January 2018 and December 2025. Patients were stratified according to the primary in-hospital prophylactic strategies for lower extremity deep venous thrombosis (DVT) and the timing of anticoagulation initiation. The primary outcome was the occurrence of DVT confirmed by color Doppler ultrasonography of both lower extremities. Safety outcomes were defined as any bleeding events during hospitalization, including intracranial hemorrhage and gastrointestinal bleeding. Associations between different prophylactic strategies, anticoagulation timing, and clinical outcomes were evaluated using multivariable logistic regression with Firth’s penalized likelihood correction. The cumulative incidence of bleeding events was further described using the Kaplan-Meier method. Results: Among the 91 patients, 17 developed DVT, with an incidence of 18.79%. Univariate analysis showed that (P < 0.001). Multivariate logistic regression analysis with Firth correction showed that compared with the single antiplatelet plus low-dose heparin group, the risk of DVT was significantly increased in the mechanical prophylaxis alone group (adjusted OR = 22.99, 95%CI: 4.16~244.50, P < 0.001) and the single antiplatelet alone group (OR = 7.90, 95% CI: 1.59~78.40, P = 0.009), while there was no significant difference in the dual antiplatelet alone group and anticoagulation alone group (P > 0.05). There was no significant difference in the incidence of any bleeding events among all regimen groups (all P > 0.05). There were statistically significant differences in the incidence of DVT among the three groups (no anticoagulation, anticoagulation initiated at 1~2 days, and anticoagulation initiated at 3~7 days) (P < 0.001). However, no significant differences were observed among the three groups in terms of any bleeding events (including intracranial hemorrhage and gastrointestinal bleeding) (P > 0.05). Furthermore, no significant differences were found in the cumulative risk of bleeding events among the groups (all P > 0.05). Conclusion: A prophylactic regimen consisting of a single antiplatelet agent combined with low-dose heparin demonstrated a more favorable risk benefit profile in reducing the risk of DVT in patients with AF-related LHI. Initiation of anticoagulation therapy with 1~2 days after admission may be both safe and effective.