膀胱癌合并冠心病患者行经尿道膀胱肿瘤切除术围手术期抗血小板药物管理

doi:10.19723/j.issn.1671-167X.2025.04.011

摘要/Abstract

摘要：

目的: 探讨合并冠状动脉粥样硬化性心脏病(coronary atherosclerotic heart disease，CAD)的膀胱癌患者行经尿道膀胱肿瘤切除术(transurethral resection of bladder tumor，TURBT)围手术期的不良事件风险因素。方法: 选择北京安贞医院2022年6月至2024年9月行TURBT手术治疗的膀胱癌患者的病例资料进行回顾性分析，所有合并CAD的患者术前均行冠状动脉计算机断层扫描(coronary computed tomography angiography, CCTA)，根据CCTA诊断和评估结果，将合并CAD的膀胱癌患者分为冠状动脉轻中度狭窄组和冠状动脉重度狭窄组。根据术前维持抗血小板治疗或进行低分子肝素(low-molecular-weight heparin, LMWH)桥接治疗，再将冠状动脉重度狭窄组分为两个亚组。术前根据心内科医生意见，调整围手术期抗凝和抗血小板药物的管理策略，随访术后30 d内患者不良事件发生率并分析其发生原因。结果: 研究共纳入80例符合标准的膀胱癌合并CAD进行TURBT的患者，冠状动脉轻中度狭窄组患者55例(68.8%)，冠状动脉重度狭窄组患者25例(31.2%)。与冠状动脉轻中度狭窄组相比，冠状动脉重度狭窄组患者出现了术后出血以及肺栓塞，但组间差异无统计学意义(P>0.05)，而冠状动脉重度狭窄组患者术后心肌梗死发生率显著增多(P=0.034)。在冠状动脉重度狭窄组患者中，有8例(32.0%)患者进行了TURBT术前LMWH桥接治疗，17例(68.0%)患者维持抗血小板治疗。与维持抗血小板治疗亚组相比，术前LMWH桥接治疗亚组出现了术后出血及肺栓塞，但两亚组间差异无统计学意义(P>0.05), 而术后发生心肌梗死的患者显著增多(P=0.032)。结论: 冠状动脉轻中度狭窄患者进行TURBT的围手术期不良事件风险较低，可在停用抗血小板药物治疗后安全地进行TURBT治疗；而冠状动脉重度狭窄的患者围手术期发生不良事件的风险较高，需要严密监测。对于合并冠状动脉重度狭窄的膀胱癌患者，在TURBT术前LMWH桥接治疗发生心肌梗死的风险较高，且维持抗血小板治疗不会增加术后出血风险，建议在平衡出血风险的前提下，维持抗血小板药物的治疗。

关键词: 膀胱癌, 经尿道膀胱肿瘤切除术, 冠状动脉粥样硬化性心脏病, 抗血栓药物

Abstract:

Objective: To explore the risk factors of adverse events during the perioperative period of transurethral resection of bladder tumor (TURBT) in bladder cancer patients with coronary atherosclerotic heart disease (CAD). Methods: We retrospectively analyzed the clinical data of bladder cancer patients who underwent TURBT in Beijing Anzhen Hospital from June 2022 to September 2024. All patients with bladder cancer and CAD underwent coronary computed tomography angiography (CCTA) for diagnosis and assessment of CAD before surgery. Based on the CCTA results, the patients with bladder cancer and CAD were divided into two groups: those with mild to moderate coronary stenosis and those with severe coronary stenosis. The severe coronary stenosis group was further divided into two subgroups based on whether they received low-molecular-weight heparin (LMWH) bridging therapy or continued their antiplatelet treatment before surgery. Perioperative anticoagulation and antiplatelet strategies were adjusted according to the opinions of the specialists. The incidence of adverse events within 30 days postoperatively was followed up and analyzed. Results: A total of 80 bladder cancer patients with CAD who underwent TURBT were included in the study. Among the 80 patients with CAD, 55 (68.8%) had mild to moderate coronary stenosis, and 25 (31.2%) had severe coronary stenosis. Compared with those had mild to moderate coronary stenosis, the patients who had severe coronary stenosis had a higher incidence of postoperative bleeding and pulmonary embolism, although the differences were not statistically significant (P>0.05). However, the incidence of postoperative myocardial infarction was significantly higher in the patients who had severe coronary stenosis (P=0.034). Among the patients with severe coronary stenosis, 8 (32.0%) received LMWH bridging therapy before TURBT, and 17 (68.0%) continued their previous antiplatelet treatment. Compared with those who continued antiplatelet treatment, the patients who received LMWH bridging therapy had a higher incidence of postoperative bleeding and pulmonary embo-lism, although the differences were not statistically significant (P>0.05). However, the incidence of postoperative myocardial infarction was significantly higher in the LMWH bridging group (P=0.032). Conclusion: Patients with mild-to-moderate coronary stenosis demonstrate relatively low perioperative risk during TURBT procedures and may safely undergo TURBT following antiplatelet therapy discontinuation. Conversely, those with severe coronary stenosis exhibit significantly higher perioperative risk and require intensive monitoring. In bladder cancer patients with concomitant severe coronary stenosis, perioperative LMWH bridging therapy is associated with increased myocardial infarction risk, whereas continued antiplatelet therapy does not elevate postoperative bleeding risk. Current evidence therefore supports maintaining antiplatelet therapy in these patients, with appropriate bleeding risk assessment.

Key words: Bladder cancer, Transurethral resection of bladder tumor, Coronary atherosclerotic heart disease (CAD), Antithrombotic drugs

中图分类号:

R737.14

缪祺, 洪保安, 张学舟, 孙志鹏, 王维, 王宇轩, 薄予轩, 赵佳晖, 张宁. 膀胱癌合并冠心病患者行经尿道膀胱肿瘤切除术围手术期抗血小板药物管理[J]. 北京大学学报（医学版）, 2025, 57(4): 698-703.

Qi MIAO, Baoan HONG, Xuezhou ZHANG, Zhipeng SUN, Wei WANG, Yuxuan WANG, Yuxuan BO, Jiahui ZHAO, Ning ZHANG. Risk assessment of perioperative adverse events and management of antiplatelet therapy in patients with bladder cancer and coronary atherosclerotic heart disease undergoing transurethral resection of bladder cancer[J]. Journal of Peking University (Health Sciences), 2025, 57(4): 698-703.

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Characteristics	Severe	Mild to moderate	P value
Total	25 (31)	55 (69)
Gender			0.062
Male	25 (100)	48 (87.3)
Female	0 (0)	7 (12.7)
Age/years	72.7±8.2	73.9±8.3	0.554
BMI/(kg/m²)	26.2±3.5	25.3±3.3	0.328
Hypertension			0.486
No	5 (20)	15 (27.3)
Yes	20 (80)	40 (72.7)
Diabetes			0.487
No	12 (48)	31 (56.4)
Yes	13 (52)	24 (43.6)
T classification at TURBT			0.520
Ta	16 (64)	31 (56.4)
T1	9 (36)	24 (43.6)
Tumor number			0.305
Single	11 (44)	31 (56.4)
Multiple	14 (56)	24 (43.6)
Tumor maximum diameter/cm			0.594
≤1	8 (32)	21 (38.2)
>1	17 (68)	34 (61.8)

Adverse events	Severe	Mild to moderate	P value
Total	25 (31)	55 (69)
Postoperative bleeding			0.136
No	24 (96)	55 (100)
Yes	1 (4)	0 (0)
Myocardial infarction			0.034
No	23 (92)	55 (100)
Yes	2 (8)	0 (0)
Pulmonary embolism			0.136
No	24 (96)	55 (100)
Yes	1 (4)	0 (0)

Characteristics	LMWH bridging	Anti-plate treatment	P value
Total	8	17
Age/years	70.4±9.6	73.9±7.5	0.328
BMI/(kg/m²)	26.7±4.4	26.0±3.3	0.677
Hypertension			0.133
No	3 (37.5)	2 (11.8)
Yes	5 (62.5)	15 (88.2)
Diabetes			0.015
No	1 (12.5)	11 (64.7)
Yes	7 (87.5)	6 (35.3)
T classification at TURBT			0.058
Ta	3 (37.5)	13 (76.5)
T1	5 (62.5)	4 (23.5)
Tumor number			0.653
Single	3 (37.5)	8 (47.1)
Multiple	5 (62.5)	9 (52.9)
Tumor maximum diameter/ cm			0.686
≤1	3 (37.5)	5 (29.4)
>1	5 (62.5)	12 (70.6)

Adverse events	LMWH bridging	Anti-plate treatment	P value
Total	8	17
Postoperative bleeding			0.137
No	7 (87.5)	17 (100)
Yes	1 (12.5)	0 (0)
Myocardial infarction			0.032
No	6 (75)	17 (100)
Yes	2 (25)	0 (0)
Pulmonary embolism			0.137
No	7 (87.5)	17 (100)
Yes	1 (12.5)	0 (0)

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