综述：长期抗凝可降低静脉血栓栓塞的复发率

问题：对于静脉血栓栓塞症（VTE）患者，长期抗凝可否降低其复发率？     

Long-term management of venous thromboembolism: a 61-year-old woman with unprovoked venous thromboembolism

Numerous randomized clinical trials have compared various durations of anticoagulant therapy with a vitamin K antagonist (ie, warfarin) for an initial episode of venous thromboembolism (VTE). Despite major advances in understanding the pathophysiology of thrombosis and its genetic basis, clinical risk factors at presentation have emerged as the primary determinant of recurrence risk. Following a minimum of 3 months of anticoagulant therapy, patients with VTE in association with transient risk factors (eg, major surgery, trauma, pregnancy) have a low annual recurrence risk, while patients without identifiable provocative risk factors have a recurrence risk of approximately 25% at 4 years with the highest annual rates occurring in the first 2 years. Extending warfarin therapy is highly effective in preventing recurrences but is associated with increased rates of major and minor bleeding. Clinical decision making therefore requires individualized assessment of recurrence and bleeding risk, coupled with patient preference. After 3 months of anticoagulant therapy for a first episode of unprovoked VTE, male sex, age older than 65 years, and an elevated D-dimer level 1 month after discontinuing anticoagulant therapy are useful parameters in identifying patients with an increased recurrence risk. The case of Ms W, a woman with unprovoked venous thromboembolism and hemorrhagic event while receiving anticoagulation, is used to illustrate clinical decision making to determine ongoing treatment.     

Effect of statins use on the prevention of venous thromboembolism： a meta-analysis

ObjectiveTo estimate the effect of statins use on the prevention of venous thromboembolism (VTE).MethodsWe systematically searched MEDLINE (1980-June 2012), EMBASE (1980-June 2012), Google Scholar, Cochrane Library, and ISI Web of Science, manually reviewed references, and contacted experts. Case-control studies and cohort studies that compared any dose of statin with no statin or placebo are included. Data extraction and study quality evaluation were independently conducted in duplicate.Results12 studies including four cohort studies and eight case-control studies were identified and eligible for meta-analysis. Upon meta-analysis, statin use was associated with a statistically significant reduction in the odds of developing VTE (OR 0.91, 95% CI 0.86–0.96).ConclusionThis meta-analysis of current and available literature suggests that statins can reduce patient's risk of developing VTE. Due to the limitations of observational study, this conclusion should be considered with caution, and additionally, specifical well-designed trials are needed.     

床旁D-二聚体检测在门诊患者排除静脉血栓栓塞的价值：一项诊断性荟萃分析

目的对目前排除静脉血栓栓塞的床旁D-二聚体检测的诊断准确性的证据进行评价。设计利用双变量回归检验变异来源，系统评价关于床旁D-二聚体检测的准确性的相关研究，并对敏感性和特异性进行评估。数据来源发表于1995年1月至2008年9月，并且于Medline和Embase中可检索到的关于床旁D-二聚体检测的诊断准确性的研究报告。评价方法纳入荟萃分析的研究需满足如下条件：对床旁D-二聚体检测与预先定义的静脉血栓栓塞的D-二聚体参考标准进行比较，人选患者为连续门诊病例，并且能够以此构建2×2表格。结果共有23项研究报告（病例总数为13959例，平均年龄为38—65岁，静脉血栓栓塞发病率为4％～51％）纳入荟萃分析。这些研究报告了两种床旁D-二聚体定性检测方法（SimpliREDD-二聚体（n=12）和Clearview Simplify D-二聚体（n=7））和两种床旁D-二聚体定量检测方法（CardiacD-二聚体（n=4）和Triage D-二聚体（n=2））。总体敏感性处于0．85（95％可信区间为0．78～0．90）至0．96（0．91～0．98）之间；总体特异性处于0．48（0．33～0．62）至0．74（0．96～0．78）之间。CardiacD-二聚体和TriageD-二聚体这两种定量检测方法评分最佳。结论在可疑静脉血栓栓塞的门诊患者中，床旁D-二聚体检测能够提供重要信息并指导治疗，在低风险患者（即临床决策规则评分较低的患者）中的价值尤为显著。     

比较磺达肝癸钠与依诺肝素预防骨科大手术后静脉血栓栓塞症疗效与安全性的Meta分析

目的系统评价磺达肝癸钠与依诺肝素在预防骨科大手术后静脉血栓栓塞症（VTE）方面的疗效与安全性。方法计算机
检索MEDLINE、EMbase、Cochrance图书馆、中国期刊全文数据库、中国生物医学文献数据库、维普数据库及万方资源数据系
统,并手工检索相关杂志、会议论文等。检索无语种限制,时间均从建库至2012年10月。按特定的纳入排除标准,筛选出符合
标准的关于磺达肝癸钠与依诺肝素预防骨科大手术后VTE发生的随机对照试验。评价指标为总VTE、深静脉血栓（DVT）、症
状性VTE、肺栓塞、大出血事件和各种不良事件等的发生率。进行质量评价和数据提取后,采用RevMan 5.1.7软件进行Meta分
析。结果共纳入随机对照研究文献5篇,均为英文文献,研究对象有1篇为膝关节大手术患者,1篇髋部骨折手术患者,其余3
篇为全髋关节置换术患者,病例数为7611例。Meta分析结果显示：磺达肝癸钠组的总VTE发生率低于依诺肝素组[RR=0.52,
95% CI（0.40,0.67）,P<0.00001];磺达肝癸钠组DVT发生率低于依诺肝素组[RR=0.49,95%CI（0.42,0.58）,P<0.00001];磺达肝
癸钠组症状性VTE发生率与依诺肝素组无统计学差异[RR=1.52,95%CI（0.80,2.88）,P=0.20];磺达肝癸钠组大出血发生率高于
依诺肝素组[RR=1.55,95% CI（1.14,2.12)）,P=0.006];磺达肝癸钠组总死亡率与依诺肝素组无统计学差异[RR=0.93,95% CI
(0.63,1.37）,P=0.72]。结论磺达肝癸钠预防骨科大手术后VTE的疗效优于依诺肝素,虽然大出血风险较依诺肝素高,但并不
增加总死亡率。
     

静脉血栓形成机理

静脉血栓栓塞是一个重要的医学问题,严重威胁人类健康。深静脉血栓形成是骨科和大手术病人、肿瘤和其它慢性病病人的主要合并症。本文主要阐述ATⅢ、PC、PS等抗凝因子的异常与静脉血栓形成的关系。     

静脉血栓栓塞症201例临床分析

目的为临床规范性诊治和预防静脉血栓栓塞症（VTE）提供参考。方法分析201例VTE患者的临床资料,包括VTE与性别、年龄、基础疾病、危险因素、诊治与预后等的关系。结果门诊患者79例,住院患者122例,男132例,女69例,男：女为1．91：1;年龄最小13岁,最大92岁,平均年龄（54．92士17．29）岁;发病高峰60～69岁57例（28．4％）。201例VTE患者中,深静脉血栓（DVT）187例（93．0％）,肺血栓栓塞症（PTE）14例（7．0％）,以血栓性静脉炎、肿瘤、骨折为主要基础疾病;多伴有高龄、制动、手术多项危险因素。治愈及好转者161例（80．0％）,死亡6例（2。9％）。结论VTE发病率男〉女,DVT占了很大比例（93．0％）;老年好发,主要基础疾病多见于血栓性静脉炎、肿瘤及骨折;加强VTE患者的管理,提高医务人员对PTE的认识及DVT的正确诊治至关重要。     

Smoking is a risk factor for venous thromboembolism

Smoking is a serious health problem and most important avoidable causes of death in the world.Smoking is the major risk factor for cardiovascular system for developing atherosclerosis which is also associated for the development thromboembolism.Smoking is one of six major modifiable risk factors for cardiac vascular disease and is the leading cause of death.1 According to the results of recent studies,venous thromboembolism (VTE) can also result from smoking.2 VTE results from a combination of hereditary and acquired risk factors,or hypercoagulable states associated with smoking.It is a common,lethal disorder that affects hospitalized and non hospitalized patients,recurs frequently,is often overlooked,and results in longterm complications including chronic thromboembolic pulmonary hypertension and the post-thrombotic syndrome.Regular smoking has been associated with VTE in different studies.     

Prevention of venous thromboembolism in medically ill patients: a clinical update

The risk of venous thromboembolism (VTE) in hospitalised medically ill patients is often underestimated, despite the fact that it remains a major cause of preventable morbidity and mortality in this group. It is not well recognised that the risk of VTE in many hospitalised medically ill patients is at least as high as in populations after surgery. This may partly be attributed to the clinically silent nature of VTE in many patients, and the difficulty in predicting which patients might develop symptoms or fatal pulmonary embolism. Two large studies, Prospective Evaluation of Dalteparin Efficacy for Prevention of VTE in Immobilized Patients Trial and prophylaxis in MEDical patients with ENOXaparin, have shown that low-molecular-weight heparins provide effective thromboprophylaxis in medically ill patients, without increasing bleeding risk. Recent guidelines from the American College of Chest Physicians recommend that acutely medically ill patients admitted with congestive heart failure or severe respiratory disease, or those who are confined to bed and have at least one additional risk factor for VTE, should receive thromboprophylaxis.     

静脉血栓栓塞症的临床研究

目的提高对深静脉血栓形成（DVT）和肺血栓栓塞症（PTE）的致病因素与临床特点的认识,以利于及早诊治。方法对广州地区确诊DVT与PTE住院患者475例的临床资料做一回顾性分析。结果近15年住院患者中DVT与VIE患者的比例呈上升趋势。这些病例有80．4％显示有危险因素,≥2个危险因素者占44．9％。最常见的危险因素为年龄≥40岁（89．5％）、卧床≥3d（51％）、手术（22．9％）、恶性肿瘤（16．6％）、糖尿病（13．5％）、高血压（10．5％）、外伤（10．5％）等。DVT患者最常见临床症状是患肢肿胀（56．0％）和疼痛（48．5％）。PTE以胸痛（28．1％）和咯血（16．1％）为主。DVT合并PTE占3．5％。DVT累及部位以左下肢多见,好发于近端静脉。DVT与PTE的辅助诊断检查以无创方法为首选。DVT患者抗凝治疗有效率为90．8％,溶检治疗为92．9％。DVT死亡率为6．1％,PTE为18．8％。结论认识DVT—PTE的各种危险因素及临床征象,并利用各种辅助检查,可提高诊断的准确性。及早治疗对该病具有重要意义。     

静脉血栓栓塞症的防治

静脉血栓栓塞症是临床上引起并发症和死亡的一个重要原因。静脉血栓栓塞症的预防和治疗策略应根据危险分层进行制订。抗凝仍然是主要治疗方法。需要更多的循证医学研究以确定适合中国静脉血栓栓塞症的预防和治疗策略。