静脉血栓栓塞症治疗的研究进展

包括深静脉血栓形成（deep vein thrombosis,DVT）和肺栓塞（pulmonary embolism,PE）的静脉血栓栓塞症（venous thromboembolism,VTE）的年发病率为0.10％～0.27％[1].约2％的PE患者在诊断前或诊断后的第一天死亡,即使给予适当的治疗PE患者3个月内的死亡率仍高达11％.死亡多是由VTE的并发疾病所致[2].VTE的长期并发症包括高达40％的DVT患者患有血栓形成后综合征,1％～4％的PE患者发生慢性血栓栓塞性肺动脉高压[3,4].     

Obesity as a risk factor in venous thromboembolism

PURPOSE: Whether obesity is an independent risk factor for pulmonary embolism or deep venous thrombosis has not been fully determined. METHODS: We used the database of the National Hospital Discharge Survey to further investigate the potential risk of obesity in venous thromboembolic disease. RESULTS: The relative risk of deep venous thrombosis, comparing obese patients with non-obese patients, was 2.50 (95% confidence interval [CI] = 2.49-2.51). The relative risk of pulmonary embolism was 2.21 (95% CI = 2.20-2.23). Obese females had a greater relative risk for deep venous thrombosis than obese males, 2.75 (95% CI = 2.74-2.76) versus 2.02 (95% CI = 2.01-2.04). Obesity had the greatest impact on both men and women aged less than 40 years. CONCLUSION: The data indicate that obesity is a risk factor for venous thromboembolic disease in men as well as women.     

Incidence of venous thromboembolism in patients hospitalized with cancer

Background

There are sparse data on the frequency of venous thromboembolism in patients with various types of cancer. We sought to determine the incidence and relative risk of venous thromboembolism, pulmonary embolism, and deep venous thrombosis in patients with malignancies.

Subjects and methods

The number of patients discharged with a diagnostic code for 19 types of malignancies, pulmonary embolism or deep venous thrombosis from 1979 through 1999 was obtained from the National Hospital Discharge Survey. Patients studied were men and women of all ages and races.

Results

In patients with any of the 19 malignancies studied, 827 000 of 40 787 000 (2.0%) had venous thromboembolism, which was twice the incidence in patients without these malignancies, 6 854 000 of 662 309 000 (1.0 %). The highest incidence of venous thromboembolism was in patients with carcinoma of the pancreas, 51 000 of 1 176 000 (4.3%), and the lowest incidences were in patients with carcinoma of the bladder and carcinoma of the lip, oral cavity or pharynx. The overall incidences of pulmonary embolism and deep venous thrombosis were also twice the rates in noncancer patients. Incidences with cancer were not age dependent. The incidence of venous thromboembolism in patients with cancer began to increase in the late 1980s.

Conclusion

Patients with cancer had twice the incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis as patients without cancer. The incidence of venous thromboembolism, pulmonary embolism and deep venous thrombosis associated with cancer differed according to the type of cancer, was comparable in elderly and younger patients, and increased in the late 1980s and 1990s.     

Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients

Background

Fewer than half of eligible hospitalized medical patients receive appropriate venous thromboembolism (VTE) prophylaxis. One reason for this low rate is the complexity of existing risk assessment models. A simple set of easily identifiable risk factors that are highly predictive of VTE among hospitalized medical patients may enhance appropriate thromboprophylaxis.

Methods

Electronic medical record interrogation was performed to identify medical admissions from January 1, 2000-December 31, 2007 (n = 143,000), and those patients with objectively confirmed VTE during hospitalization or within 90 days following discharge. Putative risk factors most predictive of VTE were identified, and a risk assessment model (RAM) was derived; 46,000 medicine admissions from January 1, 2008-December 31, 2009 served as a validation cohort to test the predictive ability of the RAM. The newly derived RAM was compared with a published VTE assessment tool (Kucher Score).

Results

Four risk factors: previous VTE; an order for bed rest; peripherally inserted central venous catheterization line; and a cancer diagnosis, were the minimal set most predictive of hospital-associated VTE (area under the receiver operating characteristic curve [AUC] = 0.874; 95% confidence interval [CI], 0.869-0.880). These risk factors upon validation in a separate population (validation cohort) retained an AUC = 0.843; 95% CI, 0.833-0.852. The ability of the 4-element RAM to identify patients at risk of developing VTE within 90 days was superior to the Kucher Score.

Conclusions

The 4-element RAM identified in this study may be used to identify patients at risk for VTE and improve rates of thromboprophylaxis. This simple and accurate RAM is an alternative to more complicated published VTE risk assessment tools that currently exist.     

Venous thromboembolism in patients hospitalized with nephrotic syndrome

Purpose

Whether pulmonary embolism in patients with the nephrotic syndrome is caused by deep venous thrombosis or renal vein thrombosis is controversial. To determine which is the likely cause of pulmonary embolism in patients with the nephrotic syndrome, we investigated data from the National Hospital Discharge Survey.

Methods

The number of patients discharged from nonfederal short-stay hospitals in the United States with a diagnostic code of nephrotic syndrome, deep venous thrombosis, renal vein thrombosis, and pulmonary embolism was obtained using ICD-9-M (International Classification of Diseases, Ninth Revision, Clinical Modification) codes.

Results

From 1979 to 2005, 925,000 patients were discharged from hospitals with the nephrotic syndrome and 898,253,000 patients did not have the nephrotic syndrome. With the nephrotic syndrome, 5000 (0.5%) had pulmonary embolism, 14,000 (1.5%) had deep venous thrombosis, and fewer than 5000 had renal vein thrombosis. The relative risk of pulmonary embolism comparing patients with the nephrotic syndrome to those who did not have it was 1.39, and the relative risk of deep venous thrombosis was 1.72. Among patients aged 18-39 years, the relative risk of deep venous thrombosis was 6.81. From 1991-2005, after venous ultrasound was generally available, the relative risk of deep venous thrombosis (all ages) was 1.77.

Conclusion

The nephrotic syndrome is a risk factor for venous thromboembolism. This is strikingly apparent in young adults. Renal vein thrombosis was uncommon. Therefore, pulmonary embolism, if it occurs, is likely to be due to deep venous thrombosis and not renal vein thrombosis.     

静脉血栓栓塞症患者的临床特点和增龄性变化

[其它论文] -Congress J Thromb an Haemost2003

Venous thromboembolic disease comparison of the diagnostic process in men and women [其它论文] -Archives of Internal Medicine2003

Venous thromboembolism in the intensive care unit [其它论文] -Critical Care Clinics2003

Venous thromboembolism in pregnancy and the puerpcrium:incidence and additional risk factors from a London perinatal database [其它论文] -British Journal of Obstetrics and Gynaecology2001

Oral contraceptives and Venous thromboembolism:a five-year national case-control study [其它论文] -Contraception2002

重视肺血栓栓塞症合并冠心病的诊断和治疗 [其它论文] -中国心血管杂志2008

内科住院患者静脉血栓栓塞症预防的中国专家建议 [其它论文] -中华老年医学杂志2009

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Epidemiology and incidence: the scope of the problem and risk factors for development of venous thromboembolism

The proportion of hospitalized patients with pulmonary embolism (PE) is increasing. Whether this represents more admissions with PE or more diagnoses made in hospitalized patients is uncertain. The proportion of hospitalized patients with deep venous thrombosis has decreased precipitously as a result of home treatment. Asians and Native Americans have a lower incidence of PE than whites or African Americans. The incidence of PE increases exponentially with age, but no age group, including infants and children, is immune. Several medical illnesses have now been shown to be associated with a higher risk for venous thromboembolism. Epidemiologic data and new information on risk factors provide insight into making an informed clinical assessment and evaluation for antithrombotic prophylaxis.     

Dose-related effect of statins in venous thrombosis risk reduction

Background

Atherosclerosis and venous thromboembolism share similar pathophysiology based on common inflammatory mediators. The dose-related effect of statin therapy in venous thromboembolism remains controversial. This study investigated whether the use of antiplatelet therapy and statins decrease the occurrence of venous thromboembolism in patients with atherosclerosis.

Methods

We conducted a retrospective cohort study reviewing 1795 consecutive patients with atherosclerosis admitted to a teaching hospital between 2005 and 2010. Patients who had been treated with anticoagulation therapy were excluded. Patients who either used statins for <2 months or never used them were allocated to the nonuser group.

Results

The final analysis included 1100 patients. The overall incidence of venous thromboembolism was 9.7%. Among statin users, 6.3% (54/861) developed venous thromboembolism, compared with 22.2% (53/239) in the nonuser group (hazard ratio [HR] 0.24; P <.001). After controlling for confounding factors, statin use was still associated with a lower risk of developing venous thromboembolism (HR 0.29; P <.001). High-dose statin use (average 50.9 mg/day) (HR 0.25; P <.001) lowered the risk of venous thromboembolism compared with standard-dose statins (average 22.2 mg/day) (HR 0.38; P <.001). Dual antiplatelet therapy with aspirin and clopidogrel decreased occurrence of venous thromboembolism (HR 0.19; P <.001). Interestingly, combined statins and antiplatelet therapy further reduced the occurrence of venous thromboembolism (HR 0.16; P <.001).

Conclusions

The use of statins and antiplatelet therapy is associated with a significant reduction in the occurrence of venous thromboembolism with a dose-related response of statins.     

肿瘤患者静脉血栓栓塞症的预测及预防用药

静脉血栓栓塞症(VTE)在肿瘤患者中发生率较高,是肿瘤患者致残、致死的重要原因之一.采取简单易行的方案预测其发生,并采取相应预防用药,有助于减少VTE的发生,减少其致残率及死亡率,延长患者的生存期.对肿瘤患者VTE早预防、早发现、早诊断、早治疗是提高肿瘤患者治疗疗效、防止并发症的关键.     

Long-term anticoagulation for venous thromboembolism: duration of treatment and management of warfarin therapy

Treatment of venous thromboembolism (VTE) should be continued until the reduction of recurrent VTE that anticoagulation is expected to achieve no longer outweighs the increase in bleeding associated with therapy, or until the patient wants to stop treatment even if treatment is expected to be of benefit. Reversibility of risk factors for VTE is the most important factor that influences risk of recurrence and duration of therapy. VTE associated with a reversible risk factor (eg, surgery) is treated for 3 months; unprovoked VTE often benefits from indefinite therapy provided patients do not have risk factors for bleeding; and cancer-associated VTE is usually treated indefinitely. A systematic approach to managing warfarin therapy improves its efficacy, safety, and acceptability.