狼疮抗凝物检测在静脉血栓栓塞症中的应用进展

狼疮抗凝物是发生静脉血栓栓塞症的危险因素之一,在静脉血栓栓塞症患者中检测狼疮抗凝物,对治疗方案抉择和疗效预后判断等方面具有重要意义。目前尚无相关文献对狼疮抗凝物检测在静脉血栓栓塞症中的应用进展进行分析总结,为加深对此类患者的认识,更好地帮助临床医生对此类患者进行合理的诊治和管理,现就有关流行病学、检测注意事项及检测结果在静脉血栓栓塞症中的价值和相关治疗进行综述。     

静脉血栓栓塞症血液系统异常及其临床应用研究进展

静脉血栓栓塞症包括肺血栓栓塞症与深静脉血栓形成,此类患者血液系统会发生变化,这些指标的变化一方面是静脉血栓栓塞症的发病原因,同时可以成为血栓形成的标记,从而为静脉血栓栓塞症的诊治提供依据.本文仅就凝血、抗凝及纤溶系统在静脉血栓栓塞症患者中的异常及其临床应用研究进展作一综述.     

肺癌合并静脉血栓栓塞症的风险评估

静脉血栓栓塞症(venous thromboembolism,VTE)是癌症常见的并发症和最常见的死亡原因之一,主要包括深静脉血栓栓塞症和肺血栓栓塞症.近年来,随着血栓栓塞性疾病研究的深入,肺癌相关性VTE已引起关注.其中,肺癌患者的预防性抗凝治疗具有很大争议性.初级预防能使肺癌相关性VTE发生风险减少,但相关研究同时提示患者出血风险提高.目前尚不推荐对肺癌患者进行常规抗凝,但对血栓风险高、出血风险低的肺癌患者进行选择性抗凝可使其获益.因此,肺癌相关性VTE的风险评估和分级可提高预防性抗凝的临床获益,减少相关出血事件.     

《美国胸科医师学院第10版静脉血栓栓塞症抗栓治疗指南》解读:静脉血栓栓塞症初始治疗

2016年1月,美国胸科医师学院更新出版了第10版静脉血栓栓塞症抗栓治疗指南(新版指南)。新版指南在第9版指南的12个临床问题的基础上,新增了3个临床问题,涵盖了静脉血栓栓塞症的溶栓治疗、抗凝治疗、介入治疗、新型抗凝药物、恶性肿瘤相关肺栓塞等问题。新版指南基础临床研究结果共提出50条推荐意见,其中20条推荐意见为强推荐。文章就静脉血栓栓塞症的初始治疗问题进行解读。     

静脉血栓栓塞症抗凝治疗微循环血栓防治专家共识

静脉血栓栓塞症(VTE)包括深静脉血栓形成和肺血栓栓塞症,是危害人类健康的常见血管疾病。规范的抗凝治疗能够有效降低VTE的发生率和病死率,减少血栓后综合征的发生。然而,临床实践中仍然有许多VTE患者并没有接受正规的抗凝治疗,或由于抗凝药物的副作用被忽略,导致了药物相关的并发症,进而引起严重的后果,实属遗憾。因此,临床上担负血栓治疗的临床医师急需规范性抗凝治疗建议。有鉴于此,本刊特发表由中国微循环学会周围血管疾病专业委员会组织国内相关领域专家制定的《静脉血栓栓塞症抗凝治疗微循环血栓防治专家共识》,从而发挥科技期刊服务于医学事业的先导作用。     

肺血栓栓塞症相关血液学因素的研究进展

肺血栓栓塞症 (PTE)与深静脉血栓形成 (DVT)属于静脉血栓性疾病 ,此类患者相关血液学指标会发生相应的变化 ,这些指标的变化可能是PTE的发病原因 ,亦可能为血栓形成的标记 ,从而为PTE的诊断提供依据。本文仅就凝血、抗凝及纤溶系统的某些指标在PTE及静脉血栓形成中的意义及其研究进展作一综述     

肺结核并发静脉血栓栓塞症二例报告并文献复习

静脉血栓栓塞症是病死率较高的血管急危重症之一。肺结核并发静脉血栓栓塞症的临床表现缺乏特异性,易被临床医生误诊或漏诊,导致死亡风险增加。笔者报道2例肺结核并发静脉血栓栓塞症患者,并对相关文献进行复习,旨在提高对肺结核并发静脉血栓栓塞症的认识并指导临床进行规范治疗。     

新型口服抗凝药物在静脉血栓栓塞症治疗中的真实世界研究

静脉血栓栓塞症是具有潜在复发风险的一类高危疾病,其主要治疗方式为抗凝治疗。传统口服抗凝药物是以华法林为代表的维生素K拮抗剂,但华法林应用具有局限性。新型口服抗凝药物如达比加群、利伐沙班、阿哌沙班、艾多沙班(依度沙班)在治疗静脉血栓栓塞症方面不劣于华法林,真实世界研究也表明其静脉血栓栓塞症复发率、主要出血事件及与临床相关的非主要出血事件较华法林相当或优于华法林。     

新型口服抗凝药物在静脉血栓栓塞症预防和治疗方面的应用进展

静脉血栓栓塞症(VTE)包括深静脉血栓形成(DVT)和肺栓塞(PE),此类疾病已成为西方住院患者死亡的常见原因之一,目前我国尚缺少相关流行病学研究资料。抗凝治疗是VTE治疗的基石,也是目前公认的标准治疗措施。抗凝治疗主要包括肠道外抗凝和肠道内抗凝,前者主要包括肝素和低分子肝素,后者则是指口服抗凝药物,临床应用最广泛的主要是维生素K拮抗剂(VKA),如华法林。口服VKA作为VTE的二级预防药物已使用     

抗凝药物在急性胰腺炎相关内脏静脉血栓中的应用进展

AP相关内脏静脉血栓是指在AP基础上发生门静脉、脾静脉和(或)肠系膜静脉等血管静脉血栓。随着辅助检查手段多样化、影像学检查技术的提高和临床医师对该病认识程度的加深, 越来越多的AP患者特别是SAP患者被发现合并内脏静脉血栓, 甚至胰源性门静脉高压症。AP相关内脏静脉血栓的治疗主要包括治疗原发病、抗凝药物的应用及消化道出血的治疗。本文就抗凝药物在AP相关内脏静脉血栓中的应用进行综述。     

The lupus anticoagulant, pulmonary thromboembolism, and fatal pulmonary hypertension.

A patient with a circulating lupus anticoagulant in the absence of systemic lupus erythematosus developed recurrent deep venous thromboses and pulmonary emboli. Pulmonary emboli recurred despite prolonged oral anticoagulant therapy and resulted in fatal pulmonary arterial hypertension. Extended anticoagulant therapy alone may not prevent recurrent thromboembolism in patients with a lupus anticoagulant. Pulmonary thromboembolism may be an important factor in the pathogenesis of pulmonary hypertension in patients with a lupus anticoagulant.     

Performance of Platelin LS and dilute Russell's viper venom for the screening of lupus anticoagulant in patients with venous thromboembolism.

Lupus anticoagulant is associated with thrombosis and pregnancy morbidity, and its detection is of major clinical importance. The nature and concentration of phospholipids strongly influence the sensitivity of activated partial thromboplastin time (aPTT) reagents to lupus anticoagulant. We investigated the ability of Platelin LS, an aPTT reagent, to screen lupus anticoagulant among 94 patients with venous thromboembolism by comparing its performance with the dilute Russell viper venom time (dRVVT). Twenty-four patients had an abnormal aPTT and dRVVT, whereas 37 only had a prolonged dRVVT. In users of oral anticoagulants (n = 56), the dRVVT prolonged more frequently than the aPTT (98.2 vs 39.3%, P < 0.0001). After the mixing study, seven patients maintained abnormal aPTT and dRVVT ratios, five of whom had prolonged mixture with both tests. The agreement in the mixing study between aPTT and dRVVT was substantial (kappa = 0.78, 95% confidence interval = 0.48-1.00). Except for one patient, the aPTT screened all cases that demonstrated phospholipid dependency of their inhibitor during the confirmatory procedure with the dRVVT. In conclusion, the aPTT using Platelin LS was highly associated with the presence of lupus anticoagulant detected by the dRVVT among patients with venous thromboembolism, and could be reliably employed as a screening assay for lupus anticoagulant.     

Antiphospholipid antibodies as risk factor for venous thromboembolism

The aim of the following study was to determine the prevalence of lupus anticoagulant (LA) and anticardiolipin antibodies (ACL) in patients with a history of venous thromboembolism (VTE). The patient group comprised 218 subjects with VTE before the age of 45, recurrent VTE or thrombosis in an unusual site. The control group consisted of 218 age, and sex-matched healthy individuals. LA and/or ACL were detected in 19 among 218 patients (8.7%). Lupus anticoagulant was found in 17 patients with VTE and in none out of 218 controls. The odds ratio for having venous thromboembolism was 14.1 (95% CI: 1.8-108.8) for patients with LA. Lupus anticoagulant is significantly associated with VTE. The prevalence of anticardiolipin was similar in patients and in controls. The results of our study indicate that anticardiolipin antibodies are not associated with venous thromboembolism.     

Quantitative assessment of thrombus burden predicts the outcome of treatment for venous thrombosis: a systematic review

PURPOSE: Clot-burden change in patients receiving anticoagulant therapy, by predicting subsequent recurrent venous thromboembolism, may provide a clinically relevant surrogate endpoint of prognostic importance. The validity of this objective measure is yet to be established. METHODS: A PubMed search was performed to retrieve articles published up to December 2003. We identified 11 randomized trials reported from 1990 to 2003 that met our study identification and selection criteria. Anticoagulant therapy subsequently approved by regulatory affairs was assessed by clot-burden change and the validated outcome measure, long-term venous thromboembolism. Two additional randomized trials, partly meeting the inclusion criteria, were included in the sensitivity analysis. RESULTS: Individual studies suggested a predictive relationship between clot-burden change and likelihood of recurrent venous thromboembolism irrespective of the particular anticoagulant. The summary treatment effects strongly favored the therapy under evaluation and were in harmony for improved clot-burden (relative risk 0.82; 95% CI, 0.76-0.88; P <0.001) and for recurrent venous thromboembolism (relative risk 0.56; 95% CI, 0.42-0.76; P <0.001). The aggregate data show a striking predictive correlation for clot-burden change and subsequent recurrent venous thromboembolism using meta-regression analysis; (correlation = 0.81, P = 0.005) validating quantitative clot-burden assessment. CONCLUSION: Clot-burden change predicts long-term outcome, providing clinically relevant, patient-specific prognostic findings that may guide duration of anticoagulant therapy as well as provide a valid surrogate endpoint for clinical trials of innovative antithrombotic therapy, allowing more efficient trials exposing far fewer patients to the hazards of ineffective therapy than is required for outcome studies. Noninvasive assessment (duplex ultrasonography) of clot-burden change is currently being deployed for use in clinical trials.     

Decision-Making in the Management of Venous Thromboembolism

Venous thromboembolism comprising deep venous thrombosis and pulmonary embolus is common. Patients with venous thromboembolism may present to a variety of health care providers, and while a significant proportion of patients begin treatment in the hospital, ambulatory management of both deep venous thrombosis and pulmonary embolus is feasible and becoming more common. Initial anticoagulant management, investigation of venous thromboembolism etiology, and decisions about extended anticoagulation require coordinated care by physicians from multiple specialties. Comprehensive management of venous thromboembolism requires coordinated care from the time of presentation in order to expedite diagnosis, initiate timely anticoagulant treatment, determine the need for extended anticoagulation based on risk of bleeding and recurrent thrombosis, and advise on thromboprophylaxis during future high-risk periods for venous thromboembolism. In this review we use case scenarios to provide an operational framework, based on current evidence-based recommendations, for informed decision-making about a number of clinical practice issues that are frequently encountered in the management of venous thromboembolism patients.     

Clinical analysis of 125 patients with the lupus anticoagulant

:A retrospective analysis of 125 consecutive lupus anticoagulant (LA) positive patients and 125 age, sex matched lupus anticoagulant negative controls is reported with the aims of defining further the clinical spectrum of disease, determining at-risk subgroups and management strategies. There was no significant difference in the incidence or pattern of complications in those with systemic lupus erythematosus (SLE) and related disorders, and those without SLE. Venous thromboembolism, immune thrombocytopenia, foetal loss, depression and hypertension were statistically more common in the LA group than in the control group. In contrast to previous reports, children aged ten years or less with the LA developed significantly more complications than controls. Patients with the LA secondary to drugs also developed complications, a finding which is also at variance with previous reports. There was a significant difference in the outcome of arterial disease (p < 0.04) and venous thromboembolism ( p < 0.001) when long term anticoagulation was part of the treatment regimen. (Aust NZ J Med 1993; 23: 151–156.)     

Low-molecular-weight heparin for the treatment of venous thromboembolism in the elderly.

Venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) is a common problem in the elderly population. Indeed, increasing age is a significant risk factor for venous thromboembolism. The treatment of venous thromboembolism in the elderly population presents certain unique problems related to aging, such as decreasing body weight, increasing renal insufficiency and numerous comorbid conditions, which complicate therapy. Treatment of venous thromboembolism in the elderly has been complicated by an increased incidence of bleeding, particularly with the use of warfarin. The risk of bleeding may be substantially reduced by carefully adjusting the warfarin dose to maintain a therapeutic INR and for this purpose anticoagulant management clinics have been shown to be useful. The low-molecular-weight heparins have been shown to be efficacious and safe for the treatment of venous thromboembolism in several clinical trials, including many patients in the older age brackets. Furthermore, these agents can safely be used in the out-of-hospital setting. Long-term use of low-molecular-weight heparin is an alternative to the use of oral anticoagulant therapy, particularly in patients with cancer or recurrent venous thromboembolism.     

Pulmonary embolism and deep vein thrombosis

Pulmonary embolism is the third most common cause of death from cardiovascular disease after heart attack and stroke. Sequelae occurring after venous thromboembolism include chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Venous thromboembolism and atherothrombosis share common risk factors and the common pathophysiological characteristics of inflammation, hypercoagulability, and endothelial injury. Clinical probability assessment helps to identify patients with low clinical probability for whom the diagnosis of venous thromboembolism can be excluded solely with a negative result from a plasma D-dimer test. The diagnosis is usually confirmed with compression ultrasound showing deep vein thrombosis or with chest CT showing pulmonary embolism. Most patients with venous thromboembolism will respond to anticoagulation, which is the foundation of treatment. Patients with pulmonary embolism should undergo risk stratification to establish whether they will benefit from the addition of advanced treatment, such as thrombolysis or embolectomy. Several novel oral anticoagulant drugs are in development. These drugs, which could replace vitamin K antagonists and heparins in many patients, are prescribed in fixed doses and do not need any coagulation monitoring in the laboratory. Although rigorous clinical trials have reported the effectiveness and safety of pharmacological prevention with low, fixed doses of anticoagulant drugs, prophylaxis remains underused in patients admitted to hospital at moderate risk and high risk for venous thromboembolism. In this Seminar, we discuss pulmonary embolism and deep vein thrombosis of the legs.     

Lupus anticoagulant.

Acquired antibodies to phospholipids form a heterogeneous group, which may be detected in vitro by the inhibition of phospholipid dependent tests of coagulation (lupus anticoagulant) and also by immunological assays, such that a combined approach is required for their reliable detection. While initially described in sufferers from systemic lupus erythematosus, these antibodies are increasingly recognised in a broad spectrum of disease, most importantly in relation to thromboembolism and recurrent fetal loss; occasionally they may also be found in otherwise healthy individuals. The mechanisms underlying the prethrombotic state associated with these antibodies have not been defined, although interference with the natural anticoagulant systems seems possible. Identification of antiphospholipid in subjects with spontaneous thromboembolism may influence therapeutic decisions, while their presence in women with recurrent fetal loss has lead to attempts to alter the outcome of further pregnancies with anticoagulant and immunosuppressive regimens, however the optimum management has not yet been determined. The recognition of these antibodies and their clinical associations is therefore highly relevant to clinical and laboratory haematology.