妊娠相关静脉血栓栓塞症评估与预防的最佳证据总结

目的 检索、分析和汇总妊娠相关静脉血栓栓塞症（pregnancy associated venous thromboembolism,PA-VTE）评估与预防的最佳证据,为临床中完善对PA-VTE患者的管理提供参考。 方法 检索UpToDate、BMJ Best Practice、Embase、Springer Link等网站或数据库中关于PA-VTE评估与预防的所有证据,包括指南、系统评价、最佳临床实践信息册、证据总结、专家共识等。检索时限为2015年1月—2021年5月。由2名研究人员独立进行文献评价,4名研究人员进行证据提取、翻译及整合。 结果 共纳入11篇文献,其中指南4篇、临床决策1篇、专家共识3篇、系统评价3篇。从PA-VTE危险因素的评估、评估时机、评估工具、基础预防、物理预防、药物预防、健康宣教7个方面总结20条证据。 结论 该研究总结了PA-VTE评估与预防的最佳证据,建议制订符合本国国情的PA-VTE风险评估工具,筛查相关危险因素并分层管理,加强孕产妇PA-VTE健康教育,以达到降低发生率的目标。     

围术期静脉血栓栓塞症预防及管理的证据总结

目的 检索、获取国内外围术期患者静脉血栓栓塞症(Venous thromboembolism,VTE)预防及管理的相关证据并对最佳证据进行总结,为临床实践提供循证依据.方法 计算机检索UpToDate、乔安娜布里格斯研究所循证卫生保健中心数据库、国际指南图书馆、美国指南网、英国国家卫生与临床优化研究所、加拿大安大略注册...     

肿瘤患者输液港相关性血栓预防及管理的最佳证据总结

目的 检索、评价和整合肿瘤患者输液港相关性血栓预防及管理的相关证据,为临床实践提供参考。方法 使用计算机检索中国知网、BMJ Best Practice、UpToDate、Cochrane Library、乔安娜布里格斯研究所循证卫生保健中心数据库、CINAHL、Embase、PubMed、中国临床指南文库、苏格兰院际指南网、美国国立指南库、美国输液护士协会网站、美国国家综合癌症网、美国临床肿瘤学会网站、欧洲肿瘤内科学会网站、安大略省注册护士协会网站中关于肿瘤患者输液港相关性血栓预防及管理的证据,包括指南、系统评价、证据总结、推荐实践及专家共识,检索时限为建库至2021年3月10日。结果 共纳入12篇文献,包括指南4篇、系统评价5篇、证据总结1篇、专家共识2篇,从风险评估、导管置入与维护、血栓筛查与诊断、预防、管理与治疗、健康教育6个方面,共总结30条最佳证据。 结论 该研究总结了肿瘤患者输液港相关性血栓预防及管理的最佳证据。护士及护理管理者可结合临床情景及患者意愿选择并应用证据,以制订科学的肿瘤患者输液港相关性血栓预防及管理方案,提升护理质量。     

Rivaroxaban for the prevention and treatment of venous thromboembolism

Venous thromboembolism (VTE) is a common and often life-threatening cardiovascular disorder. Patients undergoing total hip replacement or total knee replacement surgery are at increased risk of VTE. In this setting, clinical practice guidelines recommend the use of low molecular weight heparins, vitamin K antagonists or fondaparinux for the prevention of VTE. However, the use of these anticoagulants is beset by practical difficulties that reduce compliance to therapy and adherence to recommended guidelines. New oral anticoagulants (OACs) that are administered in fixed doses without the need for monitoring are now being introduced to clinical practice. Rivaroxaban, dabigatran and apixaban are either approved or in advanced stages of clinical development for the prevention and/or treatment of VTE. This article provides an overview of the phase III clinical development programmes for these novel OACs, with special focus on rivaroxaban. With encouraging data already emerging, the promise of a simplified single-drug approach for VTE treatment is on the horizon.     

Betrixaban for first-line venous thromboembolism prevention in acute medically ill patients with risk factors for venous thromboembolism

ABSTRACT

Introduction: Compared to other direct oral anticoagulants, betrixaban has a longer half-life, smaller peak-trough variance, minimal renal clearance, and minimal hepatic Cytochrome P (CYP) metabolism. The Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial evaluated the efficacy and safety of extended duration betrixaban compared to standard duration enoxaparin in acutely ill hospitalized patients.

Areas covered: This article describes the role of betrixaban in the prevention of venous thromboembolism (VTE) in acutely ill medical patients. This article provides a consolidated summary of the primary APEX study findings as well as prespecified and exploratory substudies. This article also provides a review of the results of studies in which other direct factor Xa inhibitors have been evaluated in an extended duration regimen in this patient population.

Expert commentary: While previous agents have demonstrated that extended duration VTE prophylaxis can be efficacious, betrixaban is the first agent to demonstrate efficacy without an increase in major bleeding. The totality of the data from the APEX trial supports extended duration betrixaban for VTE prophylaxis in the acute medically ill patient population. As such, betrixaban has been approved in the USA for extended VTE prophylaxis in at-risk acute medically ill patients.     

Guidelines for prevention of venous thromboembolism in the West and Japan

Venous thromboembolism has been a common illness even in Japan and gets increased social as well as medical attention, especially during postoperative period, while guideline for prevention of the disease has been available in the West. Since the clinical experience has shown that there are ethnic differences between Japanese and westerners in coagulability, we need a Japanese own guideline. The guideline based on experts' views in Japan has been formulating, although it is difficult to prepare an ideal one based on reliable evidences for Japanese at present. We expect this first guideline be the foundation for establishment of an ideal one.     

Aspirin in the prevention and treatment of venous thromboembolism

This review summarizes available evidence on effects of aspirin on incidence and outcomes of venous thromboembolism (VTE). From a pathophysiological point of view, inhibition of platelet aggregation is associated with an impaired thrombus formation both in an experimental model of venous thrombosis and in vivo. Epidemiological evidence in support of a beneficial effect of acetylsalicylic acid on VTE incidence is provided by the Antiplatelet Trialists' Collaboration meta-analysis of studies on the use of antiplatelet agents in cardiovascular risk reduction, showing a significant 25% risk reduction of pulmonary embolism. Moreover, a meta-analysis on older trials of antiplatelet agents in postsurgical VTE prevention and the large Pulmonary Embolism Prevention trial demonstrate a protective effect of the same magnitude: 25-30%. However, as low-molecular-weight heparins (LMWH) and vitamin K antagonists (VKA) have shown a superior efficacy and safety profile, and no direct comparisons have been made between aspirin, LMWH and VKA in prolonged use, the most recent guidelines advise against aspirin monotherapy for thromboprophylaxis in the surgical patient. Currently, there is no evidence to support a role for aspirin in air travel-related VTE. Regarding prevention of recurrent VTE, studies are ongoing to determine the potential role of aspirin after a first unprovoked VTE.     

Fondaparinux for prevention of venous thromboembolism in major orthopedic surgery

OBJECTIVE: To review clinical information related to fondaparinux, a synthetic pentasaccharide recently approved for the prevention of deep-vein thrombosis (DVT) in patients undergoing major orthopedic surgeries and for extended DVT prophylaxis after hip fracture surgery. DATA SOURCES: Primary and review articles were identified by MEDLINE (1983-June 2003) using the key words pentasaccharide, Org31540, SR90107A, DVT prophylaxis, and fondaparinux. Additional sources were found listed in articles, abstracts, and unpublished data on file from the manufacturer. Articles selected were based on their coverage of the pharmacology, pharmacokinetics, safety, and efficacy of fondaparinux. STUDY SELECTION AND DATA EXTRACTION: All of the articles identified were evaluated and all information deemed relevant was included. DATA SYNTHESIS: Fondaparinux is a selective antithrombin-dependent, indirect inhibitor of activated factor Xa. It has a favorable and predictable pharmacokinetic profile when administered subcutaneously, and has a long half-life, allowing once-daily dosing. Fondaparinux lacks in vitro cross-reactivity with heparin-induced antibodies. Major Phase III studies have demonstrated that subcutaneous fondaparinux sodium 2.5 mg given at least 6 hours postoperatively resulted in a 55% reduction in the risk of venous thromboembolism (VTE) in patients undergoing hip fracture surgery, total hip replacement surgery, or knee replacement surgery compared with standard enoxaparin therapy. It has a safety profile similar to that of enoxaparin with respect to clinically relevant major bleeding, including fatal bleeding, nonfatal bleeding, and bleeding requiring repeat surgery. The use of fondaparinux for prolonged prophylaxis after hip fracture has demonstrated further reduction in VTE events without increasing the risk of bleeding.CONCLUSIONS: Fondaparinux is the first of a new class of synthetic factor Xa inhibitors that demonstrated greater efficacy compared with enoxaparin for the prevention of VTE in major orthopedic surgery without an increase in clinically relevant bleeding. Given the favorable cost-effectiveness analysis and improved efficacy profile, fondaparinux should be considered for formulary addition for DVT prophylaxis in patients undergoing hip and knee replacement surgery. In patients undergoing hip fracture surgery, fondaparinux should be considered the DVT prophylaxis of choice. Extended thromboprophylaxis up to 28 days resulted in additional reduction in VTE (both symptomatic and venography-proven DVT) in patients with hip fracture surgery.     

Challenges in the prevention of venous thromboembolism in the elderly

Aging itself is a risk factor for venous thromboembolism, and the prevalence in the elderly of additional risk factors (e.g. cancer, orthopedic surgery, immobility) increase its intrinsic risk. Many in the medical community are reluctant to prescribe anticoagulation (for primary and secondary prevention of venous thromboembolism) to their geriatric patients for the fear that bleeding complications may outweigh the benefits. A thorough analysis of the data support the concept that the under-use of heparin in primary prevention in the elderly is more related to medical beliefs than to facts. The risk of bleeding due to oral anticoagulants (secondary prevention) is greatly reduced by keeping the International Normalized Ratio (INR) values within therapeutic ranges and carefully avoiding conditions/drugs that may interfere with such treatment. The oral direct thrombin inhibitor ximelagatran has been studied for primary (hip and knee replacement surgery) and for secondary prophylaxis of venous thromboembolism, and for acute venous thromboembolism treatment. The selective factor Xa inhibitor fondaparinux has been approved for primary prophylaxis of venous thromboembolism in hip and knee replacement surgery and in hip fracture surgery. Studies on the latter drugs, where most of the patients were > 65 years of age, further show that the fear of bleeding complications due to anticoagulation in the elderly is largely unjustified.     

Educational campaign to improve the prevention of postoperative venous thromboembolism

BACKGROUND: Recent studies have revealed considerable scope for improvement in preventing postoperative venous thromboembolism. This project comprised a baseline assessment of the use of preventive measures within the Royal Hobart Hospital, followed by the implementation and evaluation of an educational program directed at hospital staff. AIM: To determine whether the Royal Hobart Hospital's guidelines for the prophylaxis of postoperative venous thromboembolism were being utilized effectively and, if necessary, attempt to improve use of the guidelines through an educational programme. METHODS: Data were collected retrospectively from the medical records of 250 surgical patients undergoing a procedure during February 1997. Patients were classified as being at a low, medium or high risk of venous thromboembolism using two sets of criteria. The percentage of patients receiving the appropriate prophylaxis was determined. An educational programme to promote the hospital's guidelines for the prophylaxis of postoperative venous thromboembolism was then implemented. Included were presentations to staff, posters placed throughout the hospital and the wide distribution of the results and a glossy card showing the hospital's guidelines. Follow-up data were subsequently collected from another 250 surgical patients. RESULTS: Only 59% of patients received appropriate prophylaxis according to the hospital's approved guidelines, with little change when those patients with possible contraindications to thromboprophylaxis were excluded. When those patients at a high risk of venous thromboembolism were examined, only 25% were prescribed the recommended preventive measures. There was no difference between elective versus emergency surgery and the use of appropriate prophylaxis. Following the implementation of the educational programme, data collection from another 250 surgical patients revealed a significant increase (P < 0.05 by chi-square test) in the level of appropriate thromboprophylaxis to 70% of patients, with 77% of the high-risk patients being prescribed the recommended preventive measures. CONCLUSIONS: A pharmacy-based educational intervention significantly improved adherence to the hospital's guidelines for the prophylaxis of postoperative venous thromboembolism.     

预防恶性肿瘤患者静脉血栓栓塞症的临床分析

目的探讨预防恶性肿瘤患者静脉血栓栓塞症的临床方法。方法将80例恶性肿瘤住院患者随机分为干预组60例和对照组20例。干预组根据血栓弹力图及凝血检查结果进行相应干预;对照组不予干预。干预组再根据不同高凝因素分为深静脉血栓(DVT)形成组(A组)、红细胞聚集组(B组)、无血栓及红细胞聚集组(C组),每组20例。观察各组患者下肢DVT形成、肺血栓栓塞症(PTE)以及出血事件发生情况。结果住院期间,干预组DVT发生率、致死性PTE发生率均显著低于对照组。各组住院期间以及出院随访期间出血事件比较,差异均无统计学意义。结论对于恶性肿瘤患者,根据血栓弹力图及凝血提示了解血栓形成早期凝血改变,并实施积极干预,可有效降低DVT及PTE发生率。根据不同致高凝状态,寻找不同因素,采取个体化治疗,可确保治疗的有效性及安全性。     

国外静脉血栓栓塞症预防研究的文献计量学分析

目的分析国外静脉血栓栓塞症(venous thromboembolism,VTE)预防研究的现状及热点趋势,为国内护理人员开展临床工作及相关研究提供参考依据。方法检索科学网核心数据库(Web of Science Core Collection,WOSCC)中与VTE预防有关的核心期刊文献,检索时限为2005年1月1日—2020年4月27日,借助CiteSpace 5.0软件进行文献计量和聚类分析。结果国外VTE预防研究发文量整体呈上升趋势,主要聚焦物理预防、药物预防、并发症观察、危险人群识别、不同疾病人群VTE预防等5个方面,其中"预防持续时长""间歇性充气加压装置""脑卒中""抗凝""临床实践指南"和"新型口服抗凝药物"是目前的研究热点。结论 VTE预防已受到国外学者的重视,建议通过将VTE预防研究的焦点具体化、拓宽VTE重点预防人群范围、制订VTE预防护理指南等方法,推动国内VTE预防护理研究的发展,并不断提高临床护理质量,减少VTE的发生。     

The prevention and treatment of venous thromboembolism in pregnancy

Introduction: Venous thromboembolism (VTE) in pregnancy represents an important cause of maternal morbidity and mortality in developed countries, with an incidence of 0.5–2.2 per 1000 pregnancies. In addition to hemostatic changes occurring during normal pregnancy, several risk factors have been identified. Thus, a variety of clinical conditions as well as fetal and maternal risks linked to a possible anticoagulant therapy should be considered for the management of VTE during pregnancy. Unfortunately, there is a paucity of high-quality evidence from randomized trials in this field, and current recommendations are based on observational studies or evidence gathered from studies in the non-pregnant population.

Areas covered: The purpose of this review is to summarize available evidence on the prevention and treatment of pregnancy-related VTE.

Expert commentary: Although the optimal prophylactic and therapeutic dosage has not yet been established, low-molecular-weight heparin (LMWH) represents the most efficacious and safe anticoagulant during pregnancy. Thus, after an accurate risk stratification of women during pregnancy and puerperium, LMWH should be recommended to women at risk for VTE and to those ones suffering from an acute event.     

How can we reduce disagreement among guidelines for venous thromboembolism prevention?

See also Struijk‐Mulder MC, Ettema HB, Verheyen CC, Büller HR. Comparing consensus guidelines on thromboprophylaxis in orthopedic surgery. This issue, pp 678–83.     

住院患者静脉血栓栓塞症临床预防的研究进展

本文对静脉血栓栓塞症(VTE)的疾病概况、预防现况、指南规范、体系建设、措施应用等方面进行综述,目前已有多部成熟的指南和规范标准,且我国发布了最新版指南以作为临床预防工作科学、客观的参考依据和理论来源。较多医院已构建院内VTE防治体系,但是临床执行过程中仍存在许多阻力,可通过发展VTE相关的临床决策支持系统,借助智能化大数据平台使VTE预防决策标准化和科学化,以降低VTE的发生率。