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Objective:To investigate the anticoagulant causes, hemorrhagic susceptibility factors and clinical characteristics of patients with warfarin-related major bleeding in the emergency department of a general hospital.Methods:In a registry study from January 2017 to February 2020, 114 cases of warfarin-related major bleeding patients admitted to Department of Emergency Medicine, the First Affiliated Hospital of Wenzhou Medical University were enrolled. The descriptive methods were used to analyze anticoagulant causes, hemorrhagic susceptibility factors and clinical characteristics. Patients were divided into the international normalized ratio (INR) overrange group and the INR non-overrange group according to INR value during bleeding. The Chi-square test, Student’s t test, and Wilcoxon rank sum test were used to compare the differences between the INR overrange group and the INR non-overrange group. The Wilcoxon rank sum test and Student’s t test were used to analyze the characteristics of gastrointestinal tract bleeding and cerebral hemorrhage. Results:Warfarin-related major bleeding accounted for 0.36% (114/32 040) of first aid cases and 9.84% (114/1 158) of warfarin-taking cases, respectively. Seventy-seven cases (67.5%) of anticoagulant causes were related to atrial fibrillation (AF) and 32 cases (28.1%) were related to post-operative cardiac valve replacement. Of the bleeding susceptibility factors, HAS-BLED scored at 4.0 (3.0, 5.0), 84 cases (73.7%) had a history of drug use, 77 cases (67.5%) aged older than 65 years old, 65 cases (57.0%) had irregular INR monitoring, and 29 cases (25.4%) had recent increase in dose. Forty cases (35.1%) were gastrointestinal tract bleeding with the lowest hemoglobin (Hb) value and the highest score of HAS-BLED. Twenty-one cases (18.4%) were cerebral hemorrhage with the shortest prothrombin time (PT), the lowest INR value, the highest Hb, and the lowest score of HAS-BLED. Twelve cases (10.5%) died or gave up treatment in critical condition, including 6 cases of cerebral hemorrhage, 5 cases of gastrointestinal tract bleeding, and 1 case of hemoptysis. There were statistically significant differences in previous history of antiplatelet therapy, recent increase in dose, HAS-BLED score and bleeding site between the INR overrange group and the INR non-overrange group (all P<0.05). Conclusions:Among patients with warfarin-related major bleeding, AF and post-operative cardiac valve replacement are the main causes of warfarin anticoagulation. INR overrange is related to the previous history of antiplatelet therapy, recent increase in dose, and the high score of HAS-BLED. The gastrointestinal tract bleeding is the most common, with the lowest Hb value and the highest score of HAS-BLED. Cerebral hemorrhage is the second common, with the shortest PT, the lowest INR value, and the highest Hb. The incidence and mortality rates of warfarin-related major bleeding are relatively high.
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Objective:To investigate the changes of cardiomyocyte apoptosis after hypoxia/reoxygenation (H/R) regulated by microRNA-1 (miR-1).Methods:Cardiomyocyte strain H9c2 derived from rat embryonic heart tissue were cultured in vitro. The cells in logarithmic growth phase were divided into blank control group, H/R group, miR-1 mimics+H/R group, miR-1 inhibitor antisense oligonucleotide (ASO)+H/R group and microRNA negative control fragment (miRNA NC)+H/R group. The low sugar DMEM medium containing low concentration of fetal bovine serum (FBS) was used as the medium under anoxic condition. After being cultured in a closed anaerobic incubator at 37 ℃ (95% N 2 and 5% CO 2) for 12 hours, the cells were cultured with the fresh high sugar DMEM medium containing 5% FBS in a closed incubator at 37 ℃ for reproducing cardiomyocyte H/R model. The blank control group was cultured in high glucose DMEM medium containing 10% FBS in 37 ℃ and 5% CO 2 incubator. In miR-1 mimics+H/R group, miR-1 ASO+H/R group and miRNA NC+H/R group, the corresponding transfectants were mixed in high glucose DMEM medium and transfected into cells before H/R model was established, and the final concentration was 50 nmol/L. The blank control group and H/R group were added with DMEM medium at the same time. After the establishment of the model, the expression level of miR-1 was detected by real-time fluorescence quantitative polymerase chain reaction (qPCR). The expression levels of apoptosis-related proteins caspase-9, Bcl-2 and Bax were detected by Western blotting, and cardiomyocyte apoptosis was detected by flow cytometry. Results:Compared with the blank control group, the expression levels of miR-1, caspase-9 and Bax protein and the apoptosis rate of cardiomyocytes were significantly increased, while the expression level of Bcl-2 was significantly decreased, which indicated that the expression of miR-1 and the level of apoptosis were increased in H/R group. Compared with H/R group, the expressions of miR-1, caspase-9 and Bax and the apoptosis rate of cardiomyocytes in miR-1 mimics+H/R group were further increased [miR-1 (2 -ΔΔCt): 11.59±1.48 vs. 2.57±0.38, caspase-9 protein (caspase-9/β-actin): 2.59±0.12 vs. 1.56±0.20, Bax protein (Bax/β-actin): 4.09±0.38 vs. 1.97±0.13, apoptosis rate: (25.23±0.87)% vs. (17.86±0.73)%, all P < 0.01], while the expression of Bcl-2 was decreased (Bcl-2/β-actin: 0.37±0.02 vs. 0.49±0.03, P < 0.01). The expressions of miR-1, caspase-9 and Bax and the apoptosis rate were significantly decreased in miR-1 ASO+H/R group [miR-1 (2 -ΔΔCt): 1.16±0.06 vs. 2.57±0.38, caspase-9 protein (caspase-9/β-actin): 1.05±0.24 vs. 1.56±0.20, Bax protein (Bax/β-actin): 0.93±0.11 vs. 1.97±0.13, apoptosis rate: (11.19±0.85)% vs. (17.86±0.73)%, all P < 0.05], while the expression of Bcl-2 was increased (Bcl-2/β-actin: 0.84±0.17 vs. 0.49±0.03, P < 0.05). There was no significant difference in miR-1 expression, caspase-9, Bax and Bcl-2 protein expressions, and apoptosis rate between H/R+miRNA NC group and H/R group. Conclusion:The expression of miR-1 and level of apoptosis were increased in H/R cells, and miR-1 could aggravate cardiomyocyte apoptosis.