低分子肝素治疗肺栓塞18例分析

目的评价低分子肝素(olw molecular weight heparin LMWH)在治疗肺血栓栓塞症(pulmonary ehromboembo-lism,PTE)的疗效和安全性。方法将收治的36例肺血栓栓塞症患者,随机分成两组,18例为治疗组,18例为对照组,对照组应用普通肝素(unfractionatal heparin,UFH)抗凝治疗,治疗组应用低分子肝素抗凝治疗,观察其疗效及副作用。结果治疗组总有效率88.9%,对照组总有效率88.9%,副作用出现率治疗组为5.6%,对照且为16.7%。结论LMWH治疗PTE有效性与UFH相仿但安全性优于UFH。     

低分子肝素治疗冠心病不稳定型心绞痛临床观察

目的观察低分子肝素治疗不稳定型,42绞痛的临床疗效。方法随机将84例冠心病患者分为对照组和治疗组。对照组42例按内科常规治疗,治疗组42例在对照组基础上加用低分子肝素5000U,每12h1次,腹部皮下注射,7d为1个疗程。观察治疗4周后两组临床疗效、心电图等变化。结果治疗组临床疗效总有效率85．71％,心电图疗效总有效率为78．57％,均优于对照组（P〈0．05）,且未发现明显毒副反应。结论低分子肝素治疗不稳定型心绞痛优于常规治疗。     

rt-PA联合低分子肝素治疗短暂性脑缺血发作临床观察

目的观察小剂量rt-PA联合低分子肝素治疗短暂性脑缺血发作的疗效。方法选择我院2003年8月～2005年8月临床确诊短暂性脑缺血发作患者共120例，随机分为两组，小剂量rt-PA联合低分子肝素治疗组60例，对照组丹参20ml加入生理盐水中静滴，疗程均为10天。结果治疗组总有效率为90％，对照组为63％。二者总有效率比较，治疗组疗效明显优于对照组（P〈0．01），且无明显副作用。结论小剂量rt-PA联合低分子肝素治疗TIA，具有易用、高效、副作用小等特点。     

低分子肝素钙与普通肝素治疗进展型缺血性脑卒中的临床疗效观察

目的评价低分子肝素钙与普通肝素治疗进展型缺血性脑卒中的疗效和安全性。方法将80例进展型缺血性脑卒中患者随机分成治疗组和对照组各40例,对照组应用普通肝素抗凝治疗,治疗组应用低分子肝素钙抗凝治疗,观察其疗效及不良反应。结果治疗组显效率高于对照组,不良反应发生率低于对照组,差异均有统计学意义（P均〈0．05）。结论低分子肝素钙治疗进展型缺血性脑卒中的疗效及安全性优于普通肝素。     

低分子肝素治疗癌症相关急性肺血栓栓塞症的疗效

目的评价低分子肝素单药抗凝治疗癌症相关急性肺血栓栓塞症的疗效和预后。方法选择于我院就诊的60例癌症相关急性肺血栓栓塞症患者,分为试验组30例和对照组30例,对照组给予常规华法林抗凝治疗,试验组则采用低分子肝素单药抗凝治疗。观察两组患者动脉血氧分压(Pa O2)改善情况,治疗前后D-二聚体和纤维蛋白原(FIB)改善情况,预后情况。结果两组患者治疗后临床症状均有显著缓解,Pa O2、D-二聚体和纤维蛋白原(FIB)比较(P0.05),且试验组患者的改善情况显著优于对照组患者(P0.05),两组患者的病死率及血小板减少发生率均无显著差异(P0.05),但试验组患者的再栓塞率及出血事件发生率显著低于对照组患者(P0.05)。试验组患者的疾病控制率为96.7%高于对照组患者80.0%(χ2=4.0431,P=0.0444)。结论低分子肝素单药抗凝治疗癌症相关急性肺血栓栓塞症的临床疗效显著,可以有效降低再栓塞发生率及出血风险。     

低分子肝素治疗急性脑梗死临床观察

目的探讨低分子肝素对急性脑梗死抗凝干预治疗的临床疗效。方法将48例急性脑梗死患者分为低分子肝素治疗组和对照组（常规治疗组），每组24例，分别评价治疗前后神经功能缺损评分、检测治疗前后凝血指标和血液流变学指标变化。结果治疗组总有效率（83．3％）明显优于对照组（58．3％），神经功能缺损评分改善显著（P＜0．01），治疗组凝血指标凝血酶原时间、部分凝血活酶活性时间与治疗前比较差异无显著性（P＞0．05），而纤维蛋白原降低（P＜0．05），血液流变学变化较对照组明显改善。结论低分子肝素治疗急性脑梗死，有助于神经功能的改善，抗凝作用强，其方法简便安全。     

小剂量尿激酶溶栓联合抗凝治疗肺栓塞28例效果观察

1998年以来,我们采用小剂量尿激酶（UK）2h溶栓联合低分子肝素和华法林抗凝治疗肺血栓栓塞症（PTE）28例,效果良好。现报告如下。     

血栓通联合低分子肝素治疗慢性肺源性心脏病肺心功能失代偿期的疗效观察

目的观察血栓通联合低分子肝素治疗慢性肺源性心脏病肺心功能失代偿期的疗效。方法将40例慢性肺心病患者随机分为两组,均给予通畅气道、低流量吸氧、抗感染、祛痰、止咳等治疗,治疗组在上述基础上给予血栓通注射液10ml＋5%葡萄糖液250ml静脉滴注,1次/d;低分子肝素（速碧凝）0.4 ml皮下注射,1次/12h。两组均以14d为1个疗程。结果治疗组总有效率为90%,对照组总有效率为70%,两组疗效比较有显著性差异。结论联用血栓通和低分子肝素可减轻慢性肺心病肺心功能失代偿期症状,改善心功能,纠正缺氧,取得较好疗效。     

低分子肝素辅助治疗不稳定型心绞痛临床观察

目的：观察低分子肝素辅助治疗不稳定型心绞痛（UAP）的临床疗效。方法：将符合纳入标准的82例UAP患者随机分为治疗组42例和对照组40例,两组患者均接受硝酸酯类、β受体阻滞剂、血管紧张素转换酶抑制剂、他汀类药物、阿司匹林等治疗,治疗组患者另予以低分子肝素5000U／a皮下注射,连续7d,两组患者均连续治疗半月后评定疗效。结果：治疗组总有效率达88．1％,对照组总有效率为77．5％,两组患者疗效差异没有统计学意义（P〉0．05）,两组患者心绞痛发作情况均有明显好转,且治疗组患者心绞痛日发作次数和发作持续时间均低于对照组（P〈0．05和P〈0．01）。结论：低分子肝素辅助治疗不稳定型心绞痛疗效确切,安全可靠,值得临床推广。     

血栓通与低分子肝素治疗不稳定心绞痛的临床观察

目的:观察血栓通与低分子肝素联合应用对不稳定心绞痛的疗效。方法:88例患者随机分为治疗组50例,对照组38例。对照组用常规方法治疗,治疗组在此基础上加用血栓通与低分子肝素治疗。结果:治疗组症状改善总有效率为90.0％,与对照组比较差异显著(P<0.01)。结论:血栓通与低分子肝素联合治疗不稳定心绞痛效果显著。     

络泰联合低分子肝素治疗急性肺栓塞的临床研究

目的评价络泰联合低分子肝素治疗急性肺栓塞的疗效。方法将确诊的102例急性肺栓塞患者分为2组,A组患者(n=55)单用低分子肝素4100IU,皮下注射,每日2次,共12天。B组患者(n=57)在A组的治疗方案的基础上,加用络泰粉剂0.8g,溶于生理盐水200m l静脉滴注,1小时滴完,每日1次。对比观察疗效。结果2组患者治疗后的各项临床和实验指标均有明显改善,A组治疗有效率为69.1%,B组为75.4%,B组的有效率明显高于A组,差异有统计学意义。鼻出血和皮下出血并发症两组无差异。结论络泰联合低分子肝素治疗急性肺栓塞是安全、有效的。     

Low molecular weight heparin versus unfractionated heparin in the initial treatment of venous thromboembolism

In this review, we analyze data from randomized trials in which low molecular weight heparin was compared with unfractionated heparin, both to estimate the treatment effect of low molecular weight heparin in the initial treatment of venous thromboembolism and to evaluate the effect of the varied proportion of included cancer patients (6% to 22.7%) on the incidence of outcome events (recurrence of venous thromboembolism, bleeding, and mortality) and on the estimated treatment effect. Low molecular weight heparin has been extensively investigated in patients with deep vein thrombosis, but few trials have included patients with pulmonary embolism. The risk of recurrence of venous thromboembolism (odds ratio, 0.77; 95% CI, 0.56-1.04), major bleeding (odds ratio, 0.60; 95% CI, 0.38-0.95), and mortality (odds ratio, 0.72; 95% CI, 0.55-0.96) was less with low molecular weight heparins compared with unfractionated heparin. The proportion of cancer patients in these studies had a statistically significant effect on the incidence of recurrent venous thromboembolism (P = 0.03) and mortality (P = 0.002), but no influence on the estimated treatment effects of low molecular weight heparins. Low molecular weight heparin is effective and safe in the initial treatment of venous thromboembolism.     

急性肺血栓栓塞患者血清酶学及肌钙蛋白I的变化

目的观察急性肺血栓栓塞（PTE）患者血清酶学及肌钙蛋白Ⅰ（TnI）的变化，了解其与估测肺动脉收缩压、右心运动功能及预后的关系。方法519例PTE患者来自北京24家医院参与的国家“十五”科技攻关课题——肺栓塞规范化诊治方法的研究。根据2001年5月中华医学会呼吸病学分会制定的《肺血栓栓塞症的诊断与治疗指南（草案）》的诊断标准确定大面积、次大面积、非大面积肺栓塞患者。大面积、次大面积肺栓塞患者采用溶栓治疗，非大面积肺栓塞患者采用抗凝治疗。按中心随机方法将患者分组，应用尿激酶和重组组织型纤溶酶原激活剂及普通肝素和低分子肝素。结果（1）大面积肺栓塞患者治疗前血清丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）、肌酸激酶（CPK）、乳酸脱氢酶（LDH）水平[（74±33）、（88±40）、（157±75）、（419±264）U／L]明显高于次大面积肺栓塞患者[（52±21）、（43±18）、（75±30）、（284±176）U／L]和非大面积肺栓塞患者[（38±13）、（35±11）、（78±24）、（239±178）U／L]；（2）非大面积肺栓塞患者应用普通肝素治疗7d后血清ALT[（84±39）U／L]明显高于应用低分子肝素患者[（67±26）U／L]；（3）519例患者中45例肺动脉收缩压≥80mmHg（1mmHg=0．133kPa），治疗前存在右心运动功能减弱169例，预后不良48例。大面积肺栓塞患者中17例（41．5％）AIJT升高，次大面积中76例（45．5％），非大面积中26例（54．5％）。大面积肺栓塞患者中24例（54．4％）LDH升高，次大面积中68例（40．2％），非大面积中15例（30．8％）；（4）39例血清TnI≥0．07μg／L的患者中右心功能减弱24例（63．3％），预后不良者8例（24．2％）。结论（1）急性PTE患者可出现血清ALT、ASF、CPK、LDH水平升高；（2）非大面积肺栓塞患者应用抗凝治疗，普通肝素较低分子肝素更易引起血清ALT升高；（3）血清ALT、LDH以及TnI的升高与PTE患者的肺动脉收缩压、右心运动功能及预后密切相关，其变化可能有助于对急性肺栓塞患者进行危险分层。     

Incidence of pulmonary thromboembolism (PTE) and new guidelines for PTE prophylaxis in Japan

Incidence of venous thromboembolism (VTE), which had been considered a relatively rare disease in Japan, has been on the increase in recent years as eating habits have become more similar to those of the West. We have investigated the recent incidence data of perioperative pulmonary thromboembolism (PTE) in Japan and have established guidelines for the prevention of VTE. Recommended thromboprophylaxis is early ambulation for low risk group, elastic stocking (ES) or intermittent pneumatic compression (IPC) for moderate risk group, IPC or low dose unfractionated heparin (LDUH) for high risk group, and LDUH + IPC or LDUH + ES for highest risk group. The management fee for PTE prophylaxis was established and covered by health insurance in April 2004. Surprisingly, the incidence of perioperative PTE decreased just after this guideline was issued. After accumulation of further evidence and application of pharmacological agents, such as low molecular weight heparin, we will establish the advanced guidelines in the future.     

前列地尔联用低分子量肝素治疗老年骨折非大面积肺栓塞疗效观察

目的：观察前列地尔联用低分子肝素治疗老年骨折后并发非大面积肺栓塞的疗效。方法：老年骨折后并发非大面积肺栓塞的患者62例，随机分成2组。对照组30例予低分子量肝素钠4100U皮下注射，每12h1次，疗程7～14d；治疗组在予低分子量肝素钠的同时予前列地尔脂微球载体制剂。两组患者同时接受动脉血气、血氧饱和度（SaO2）、超声心动图检查。结果：治疗组与对照组比较，治疗后PaO2、PaC02、SaO2、PASP、MPAP、RAP、PVR、RVEF水平变化有统计学差异（P〈0．05）。对照组总有效率为66．7％o，治疗组总有效率为90．6％，两组比较差异有统计学意义。结论：采用前列地尔联用低分子量肝素可以有效治疗老年骨折后并发非大面积肺栓塞的患者，且出血风险小。     

Randomized comparison of enoxaparin with unfractionated heparin following fibrinolytic therapy for acute myocardial infarction.

AIMS: To compare the efficacy and safety of low molecular weight heparin with unfractionated heparin following fibrinolytic therapy for acute myocardial infarction. METHODS AND RESULTS: Three-hundred patients receiving fibrinolytic therapy following acute myocardial infarction were randomly assigned to low molecular weight heparin as enoxaparin (40 mg intravenous bolus, then 40 mg subcutaneously every 8 h, n=149) or unfractionated heparin (5000 U intravenous bolus, then 30 000 U. 24 h(-1), adjusted to an activated partial thromboplastin time 2-2.5x normal, n=151) for 4 days in conjunction with routine therapy. Clinical and therapeutic variables were analysed, in addition to use of enoxaparin or unfractionated heparin, to determine independent predictors of the 90-day composite triple end-point (death, non-fatal reinfarction, or readmission with unstable angina). The triple end-point occurred more frequently in patients receiving unfractionated heparin rather than enoxaparin (36% vs. 26%; P=0.04). Logistic regression modelling of baseline and clinical variables identified the only independent risk factors for recurrent events as left ventricular failure, hypertension, and use of unfractionated heparin rather than enoxaparin. There was no difference in major haemorrhage between those receiving enoxaparin (3%) and unfractionated heparin (4%). CONCLUSION: Use of enoxaparin compared with unfractionated heparin in patients receiving fibrinolytic therapy for acute myocardial infarction was associated with fewer recurrent cardiac events at 90 days. This benefit was independent of other important clinical and therapeutic factors.     

New therapeutic opportunities for heparins: What does low molecular weight heparin offer?

New advances in antithrombotic therapy include direct thrombin inhibitors and low molecular weight heparins and heparinoids. Low molecular weight heparins and heparinoids have improved pharmacologic and pharmacokinetic properties when compared with unfractionated heparin. Low-molecular weight heparins are effective in the prevention of venous thromboembolism in general surgical patients, orthopedic patients, spinal cord injury patients, and general medical patients. At equipotent antithrombotic doses, low molecular weight heparins produce less bleeding. Low molecular weight heparins given in fixed doses subcutaneously have been shown to be as effective or more effective and safer than unfractionated heparin given intravenously with regular monitoring in the treatment of venous thromboembolic disease. Recent studies have demonstrated that low molecular weight heparins are effective in reducing the risk of death and myocardial infarction in patients with unstable angina and are as effective as intravenous heparin when given subcutaneously without monitoring. Preliminary data indicate that low molecular weight heparins may be effective in improving outcomes in patients with ischemic stroke.     

Venous thromboembolism prophylaxis for the medical patient: where do we stand?

Acutely ill medical patients are at moderate to high risk of venous thromboembolism: ~10 to 30% of general medical patients may develop deep vein thrombosis or pulmonary embolism, and the latter is a leading contributor to deaths in hospital. Medical conditions associated with a high risk of venous thromboembolism include cardiac disease, cancer, respiratory disease, inflammatory bowel disease, and infectious diseases. Predisposing risk factors in medical patients include a history of venous thromboembolism, history of malignancy, complicating infections, increasing age, thrombophilia, prolonged immobility, and obesity. Heparins, including unfractionated and low molecular weight, as well as fondaparinux have been shown to be effective agents in prevention of VTE in this setting. However, it has not yet been possible to demonstrate a significant effect on mortality rates in this population. In medical patients, unfractionated heparin has a higher rate of bleeding complications than low molecular weight heparin. There is no evidence for the use of aspirin, warfarin, or mechanical methods. We recommend either low molecular weight heparin or fondaparinux as safe and effective agents in the thromboprophylaxis of medical patients.     

Prevention of venous thromboembolism in internal medicine and neurology

Many hospitalized patients are under an increased risk of venous thromboembolism. They should have adequate pharmacological prophylaxis. Clinical studies including meta-analyses prove that low molecular weight heparin prophylaxis of venous thromboembolisms is equally effective as that employing unfractionated heparin and it features less bleeding complications. The effectiveness of pharmacological prophylaxis with low molecular weight heparin in hospitalized patients at internal medicine departments has been proven by the MEDENOX study when enoxaparin in a dose of 40 mg was administered subcutaneously and the PREVENT study when subcutaneous dalteparin 5 000 units j. was administered daily. In the MEDENOX study, enoxaparin administration was confirmed to decrease the relative risk of venous thromboembolisms by 63% without increasing any adverse effects during the prophylaxis and the PREVENT study showed that dalteparin administration was followed by a highly significant reduction of asymptomatic venous thromboses in hospitalized patients. According the ACCP guideline for thromboprophylaxis in hospitalized internal medicine patients with clinical risk factor of venous thromboembolism (tumors, heart failures, sepsis, VTE history and serious pulmonary condition), low molecular weight heparin or mini-doses of unfractionated heparin are to be administered. The recent recommendations discourage the use of acetyl-salicylic acid in monotherapy treatment for venous thromboembolism prevention.