以肺血栓栓塞症为首发表现的再生障碍性贫血诊断及治疗策略一例报道

肺血栓栓塞症是临床常见的危重症之一,规范、足量的抗凝治疗是溶解肺动脉血栓、改善患者症状、降低死亡风险的重要手段。而对于同时合并血小板减少的肺血栓栓塞症患者,查找病因并明确诊断、预防出血与抗凝治疗仍是诊治难点。本文报道1例以肺血栓栓塞症为首发表现的再生障碍性贫血患者的临床诊治经过,以期提高临床工作者对该类疾病的认识。分析表明,再生障碍性贫血患者发生静脉血栓栓塞症风险较高,综合平衡抗凝获益及其出血风险、强化医患沟通是做出合理临床决策及治疗成功的关键。     

肺癌合并静脉血栓栓塞症的临床新进展

目前肺癌的发病率和死亡率在中国城市中列居首位,静脉血栓栓塞症(venous thromboembolism,VTE)是恶性肿瘤患者常见的并发症,成为肿瘤患者的第2位死因.恶性肿瘤导致VTE发生的原因与凝血纤溶系统、血小板、血管内皮细胞等因素有关;另外,肿瘤本身及其相关治疗也增加了肺癌并发VTE的风险.2009年美国胸科协会及欧洲心脏协会发表的肿瘤患者VTE防治指南指出,抗凝治疗是肺癌合并VTE患者的基本治疗措施,但要注意出血风险.     

普外科疾病合并静脉血栓栓塞症患者围术期的治疗

目的:研究普外科合并静脉血栓栓塞症(VTE)患者,围术期抗凝治疗和临床管理的方案。方法:术前对患者进行VTE风险评估,选择围术期抗凝治疗方案,分析围术期不良事件(出血、血栓复发)发生情况并对不良事件相关因素进行研究。结果:149例入组患者分为四组,术前无抗凝14例、华法令抗凝无桥接组27例、华法令抗凝桥接组87例、新型口服抗凝药组21例。其中进行围术期抗凝者,下肢血栓多为中央型或混合型、同时存在深静脉血栓形成(DVT)及肺血栓栓塞症(PE)、合并恶性肿瘤、易栓症检测异常、VTE多为3个月之内、VTE多为中高风险、术前进行化疗并经外周静脉穿刺中心静脉置管(PICC)置管(P<0.05)。围术期桥接抗凝者血栓复发率(2.3%)明显低于无桥接组(9.7%)(P<0.05)。与血栓复发的相关因素为既往已有VTE复发(P<0.001)。围术期桥接抗凝者出血率(16.1%)与无桥接组(4.8%)无明显差异(P>0.05)。与出血相关的危险因素为年龄(P<0.01),将年龄≥65岁的患者再进行出血相关因素分析,手术分级、桥接抗凝有统计学差异(P<0.05)。80岁以上低分子肝素0.6 mL/24 h或0.4 mL/12 h桥接抗凝患者无血栓复发及大出血。新型口服抗凝药组既无血栓复发也无出血病例。结论:对于普外科疾病合并VTE患者,中高复发风险、低出血风险患者选择低分子肝素桥接抗凝。既往有过反复VTE发作或停抗凝药后复发患者围术期血栓再复发的风险较大。高龄、手术规模较大、需要进行桥接抗凝者,则要警惕出血的风险。高龄患者小剂量抗凝加穿医用弹力袜、抬高患肢、早期离床活动,更为安全有效。新型口服抗凝药将可能成为有效、安全的首选抗凝方案。     

2018版中国《肺血栓栓塞症诊治与预防指南》解读之六:静脉血栓栓塞症预防策略

静脉血栓栓塞症(VTE)包括深静脉血栓形成(DVT)和肺血栓栓塞症(PTE),是住院患者的常见并发症,也是造成住院患者医疗费用增加、住院时间延长的主要原因,已成为医院管理者和临床医务人员面临的严峻问题。2018版中国《肺血栓栓塞症诊治与预防指南》强调院内VTE预防的重要性,在对患者进行血栓风险、出血风险评估的基础上,结合既往循证医学证据、中国国情及相关临床实践,针对VTE的科学预防提出专家推荐意见。推荐意见为临床上VTE的预防提供了更多依据和指导,以期减少住院相关VTE事件的发生,为患者创造一个更加安全的医疗环境。     

肾病综合征抗凝治疗的时机和药物选择

肾病综合征(NS)患者体内存在高凝状态,易导致静脉血栓栓塞症(VTE)发生,包括下肢深静脉血栓塞和肾静脉血栓,并可引起肺动脉栓塞(PE),严重威胁患者的生命安全.文献报道NS患者VTE的发生率在7.2％ ～62％.南京军区南京总医院全军肾脏病研究所一项前瞻性研究观察了膜性肾病患者VTE的发生率证实,VTE发生率高达36％,其中肾静脉血栓33％,PE17％,且多数患者并无典型血栓栓塞症状.因此,对于可能发生VTE的患者抗凝治疗显得尤为必要.但长期抗凝治疗可导致患者医疗费用的增加,出血并发症增多,严重者甚至威胁生命.因此,正确把握抗凝治疗的时机,选择合理的抗凝药物,对改善NS患者预后,减少并发症,提高生活质量有重要意义.     

益气活血中药联合新型口服抗凝剂预防心房颤动患者血栓栓塞性疾病有效性及安全性的研究进展

心房颤动是临床常见的心律失常类型,且以非瓣膜性心房颤动(NVAF)为主,其最严重的并发症为血栓栓塞性疾病。新型口服抗凝剂(NOACs)是目前预防心房颤动患者血栓栓塞性疾病的首选药物,但其存在抗凝获益与出血风险的矛盾。目前,采用益气活血中药联合NOACs预防心房颤动患者血栓栓塞性疾病非常普遍,但其安全性的研究报道少见。本文通过分析文献发现,益气活血中药联合NOACs能增强心房颤动患者的抗凝效果,降低血栓栓塞性疾病的发生风险,且可以减少出血风险。     

肺癌合并静脉血栓栓塞症的研究进展

肺癌是全球范围内发病率和病死率最高的恶性肿瘤.静脉血栓栓塞症(venous thromboembolism,VTE)是肺癌患者常见的并发症,其与肿瘤的不同组织学类型及病理分期、肿瘤治疗方式相关.肺癌患者接受手术、放化疗等治疗措施提高了血栓事件的发生率.而VTE与肿瘤的进展、血管生成和转移等密切相关,形成恶性循环,增加了患者的死亡率.由于深静脉血栓直接威胁肿瘤患者生命,最近关于预测癌症患者血栓事件的风险模型及血清标志物成为研究热点,以期帮助识别可能并发VTE的高危患者,有助于早期诊断及预防.     

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。     

祝贺北京协和医院郑月宏教授牵头完成《静脉血栓栓塞症抗凝治疗微循环血栓防治专家共识》

正静脉血栓栓塞症(VTE)是一种高发病率和高致死率的疾病抗凝治疗作为VTE的最基础治疗,能够抑制VTE血栓蔓延,促进血栓再溶和管腔再通,有效减少VTE并发症的发生但现实中仍有许多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,导致了药物相关并发症目前,国内缺乏专门     

静脉血栓栓塞症抗凝靶点的研究现状与前景

静脉血栓栓塞症（VTE）包括深静脉血栓形成（DVT）和肺血栓栓塞症（PTE），其是住院患者非预期死亡的重要原因，已构成医疗质量和患者安全的潜在风险，且近10年来其造成的疾病负担逐年增加。目前，抗凝治疗是防治VTE的关键措施，尽管直接口服抗凝药（DOACs）较传统抗凝药更有效、安全且便利，但仍无法平衡治疗期间的抗栓与出血风险，故寻找更安全的抗凝靶点是VTE抗凝药研发的重点。本文以抗凝靶点为切入点总结了VTE抗凝药的研究现状，即凝血酶和凝血因子Ⅹa抑制剂虽已广泛用于临床，但适用人群受限，组织因子/凝血因子Ⅶa复合物、凝血因子Ⅷa及凝血因子Ⅸa抑制剂存在出血风险，凝血因子Ⅴa、凝血因子ⅩⅢa及凝血因子Ⅻa抑制剂的抗栓效果仍有待进一步评估，凝血因子Ⅺa可能是当前最有希望的抗凝靶点之一。     

Recurrent thromboembolism in cancer patients: incidence and risk factors

In contrast with the paucity of data on the risk of a first episode of thrombosis in cancer patients, the frequency of recurrent thromboembolism in patients with malignancy has been extensively investigated, both during anticoagulation and after its cessation. Cancer patients are more likely to develop recurrent thromboembolism and major bleeding during anticoagulation than patients without malignancies. These events are more pronounced during the first weeks of treatment and increase with cancer severity. Since they are not associated with anticoagulant intensities outside the therapeutic range, possibilities for improvement using the current paradigms of anticoagulation seem limited and new treatment strategies should be developed. In this regard, the use of low-molecular-weight heparins for initial treatment and long-term anticoagulation in cancer patients with venous thrombosis seems promising. Furthermore, patients with active cancers exhibit a particularly high risk of recurrent venous thromboembolism after the cessation of anticoagulation. In view of the persisting high risk for recurrent thrombotic events in cancer patients, and the acceptable risk of bleeding, prolonged warfarin treatment should be considered in such patients for as long as the cancer is active.     

Treatment of DVT: how long is enough and how do you predict recurrence

Abstract Currently available anticoagulants are effective in reducing the recurrence rate of venous thromboembolism (VTE). However, anticoagulant treatment is associated with an increased risk for bleeding complications. Thus, anticoagulation has to be discontinued when benefit of treatment no longer clearly outweigh its risks. The duration of anticoagulant treatment is currently framed based on the estimated individual risk for recurrent VTE. The incidence of recurrent VTE can be estimated through a two-step decision algorithm. Firstly, the features of the patient (gender), of the initial event (proximal or distal deep vein thrombosis or pulmonary embolism), and the associated conditions (cancer, surgery, etc) provide essential information on the risk for recurrence after anticoagulant treatment discontinuation. Secondly, at time of anticoagulant treatment discontinuation, d-dimer levels and residual thrombosis have been indicated as predictors of recurrent VTE. Current evidence suggests that the risk of recurrence after stopping therapy is largely determined by whether the acute episode of VTE has been effectively treated and by the patient’s intrinsic risk of having a new episode of VTE. All patients with acute VTE should receive oral anticoagulant treatment for three months. At the end of this treatment period, physicians should decide for withdrawal or indefinite anticoagulation. Based on intrinsic patient’s risk for recurrent VTE and for bleeding complications and on patient preference, selected patients could be allocated to indefinite treatment with VKA with scheduled periodic re-assessment of the benefit from extending anticoagulation. Alternative strategies for secondary prevention of VTE to be used after conventional anticoagulation are currently under evaluation. Cancer patients should receive low molecular-weight heparin over warfarin in the long-term treatment of VTE. These patients should be considered for extended anticoagulation at least until resolution of underlying disease. Abbreviated abstract The risk for recurrent venous thromboembolism can be estimated through a two-step algorithm. Firstly, the features of the patient (gender), of the initial event (proximal or distal deep vein thrombosis or pulmonary embolism), and the associated conditions (cancer, surgery, etc) are essential to estimate the risk for recurrence after anticoagulant treatment discontinuation. Secondly, a correlation has been shown between d-dimer levels and residual thrombosis at time of anticoagulant treatment discontinuation and the risk of recurrence. Currently available anticoagulants are effective in reducing the incidence of recurrent venous thromboembolism, but they are associated with an increased risk for bleeding complications. All patients with acute venous thromboembolism should receive oral anticoagulant treatment for three months. At the end of this treatment period physicians should decide for definitive withdrawal or indefinite anticoagulation with scheduled periodic re-assessment of the benefit from extending anticoagulation.     

Workshop: Special problems in anticoagulation therapy: Cancer and venous thromboembolism-temporary discontinuation of warfarin for surgery and invasive procedures

Health care providers monitoring anticoagulated patients are often asked to make recommendations regarding anticoagulant management during periods when illness or treatment may complicate anticoagulant therapy. Two particularly difficult clinical problems concern the indications for and management of anticoagulant therapy in patients with cancer and the management of anticoagulated patients who must undergo some type of surgical procedure. Cancer is a significant risk factor for a variety of thromboembolic disorders, particularly venous thromboembolism. Venostasis from immobility, vessel wall damage from tumor invasion, and especially tumor-mediated activation of the coagulation system are important contributors to the prethrombotic state in cancer patients. The risk of venous thromboembolism is greatest during surgery, chemotherapy, and long-term use of central venous catheters. For selected patients, prophylaxis with subcutaneous heparin, low-intensity warfarin, or very low-intensity warfarin may substantially reduce this risk. A related concern for primary care clinicians is the increasing evidence that idiopathic venous thromboembolism may be the first manifestation of occult cancer. Whether and how these patients should be screened for malignancy is currently uncertain. Prior to surgical procedures in anticoagulated patients, clinicians must compare the risk of bleeding if anticoagulation is continued with the risk of recurrent thrombosis if anticoagulation is stopped. Bleeding risk is influenced by how a specific procedure affects the ability to assess and control bleeding and the intensity of anticoagulation at the time of the procedure. Thromboembolism risk is determined by the specific indication for the anticoagulation and the length of time during which anticoagulant therapy must be discontinued. Guidelines are suggested for perioperative anticoagulant management of patients with different thromboembolic disorders undergoing a variety of surgical procedures.     

肺癌患者并发静脉血栓与肺栓塞的危险因素分析简

目的 探讨肺癌患者并发静脉血栓或肺栓塞的高危因素.方法 分析我院收治的35例肺癌合并静脉血栓栓塞患者资料,选择同期未发生静脉血栓的病例资料做对照,探求肺癌并发静脉血栓或肺栓塞的危险因素.结果 （1）静脉血栓发生时间构成以确诊后3个月内比重最高,占31.4%;静脉血栓发生部位以左下肢深静脉血栓为主,占40.0%.（2）腺癌、高病理分级、D-二聚体升高是肺癌合并静脉血栓或肺栓塞的独立危险因素,各因素的OR值分别为7.207、3.480、2.863.结论 肺癌诊断3个月内是并发静脉血栓栓塞的高发时段;肿瘤分级高、腺癌、D-二聚体水平升高的肺癌患者易发生静脉血栓栓塞,临床应对上述因素高度警惕,及早进行预见性治疗.     

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.     

Posttreatment ultrasound-detected residual venous thrombosis: a risk factor for recurrent venous thromboembolism and mortality

PURPOSE OF REVIEW: The cumulative risk of recurrent venous thrombosis may rise to 30% over 8 years. Extended oral anticoagulation is effective but major bleeding is increased. To balance these risks attention has focused on identifying patients with the highest likelihood of recurrence for whom continued therapy is most beneficial. Another issue of interest has been the increased probability of death after venous thrombosis, due primarily to malignancy but also to vascular disease. RECENT FINDINGS: Unprovoked events and cancer are known to be associated with recurrent thrombosis. Residual posttreatment thrombosis confirmed by compression ultrasound is regarded as another risk for recurrence. Confounders in the published studies are the patient mix and the ultrasound technique employed. Other variables such as gender and D-dimer may also predict risk. Although arterial disease is increased in patients with venous thromboses, the association between idiopathic venous thromboembolism and atherosclerosis remains circumstantial. SUMMARY: There are no validated approaches for predicting recurrent venous events. Ultrasound interrogation for residual thrombosis after primary therapy may improve treatment stratification by defining patients suitable for extended anticoagulation.     

Risk factors for recurrent venous thromboembolism

Recurrent venous thromboembolism (VTE) is frequent and can be fatal. Long-term antithrombotic treatment reduces the risk of recurrent VTE but increases the risk of bleeding and, therefore, cannot be proposed for all patients. Predicting the probability of recurrence in an individual patient is of utmost importance for assessing the risk-benefit ratio of long-term anticoagulation. Multiple clinical risk factors for recurrent VTE have been identified which include: unprovoked first episode, anatomical proximal location, male gender, residual venous thrombosis, cancer and antiphospholipid syndrome. d-dimer level after discontinuation of oral anticoagulation can help to predict the risk of recurrence with a good negative predictive value. Finally, genetic polymorphisms and rare inherited deficiencies of natural anticoagulant proteins do not seem to be strongly associated to recurrence. New antithrombotic drugs may, in the near future, improve the safety and of long-term anticoagulation treatment.     

Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis

A small proportion of patients with deep vein thrombosis develop recurrent venous thromboembolic complications or bleeding during anticoagulant treatment. These complications may occur more frequently if these patients have concomitant cancer. This prospective follow-up study sought to determine whether in thrombosis patients those with cancer have a higher risk for recurrent venous thromboembolism or bleeding during anticoagulant treatment than those without cancer. Of the 842 included patients, 181 had known cancer at entry. The 12-month cumulative incidence of recurrent thromboembolism in cancer patients was 20.7% (95% CI, 15.6%-25.8%) versus 6.8% (95% CI, 3.9%- 9.7%) in patients without cancer, for a hazard ratio of 3.2 (95% CI, 1.9-5.4) The 12-month cumulative incidence of major bleeding was 12.4% (95% CI, 6.5%-18.2%) in patients with cancer and 4.9% (95% CI, 2.5%-7.4%) in patients without cancer, for a hazard ratio of 2.2 (95% CI, 1.2-4.1). Recurrence and bleeding were both related to cancer severity and occurred predominantly during the first month of anticoagulant therapy but could not be explained by sub- or overanticoagulation. Cancer patients with venous thrombosis are more likely to develop recurrent thromboembolic complications and major bleeding during anticoagulant treatment than those without malignancy. These risks correlate with the extent of cancer. Possibilities for improvement using the current paradigms of anticoagulation seem limited and new treatment strategies should be developed.     

The optimal duration of anticoagulant treatment following pulmonary embolism

The optimal course of oral anticoagulant therapy is determined according to the risk of recurrent venous thromboembolism after stopping therapy and the risk of anticoagulant-related bleeding. Clinical risk factors appear to be important in predicting the risk of recurrence whereas the influence of biochemical and morphological tests is uncertain. The risk of recurrent venous thromboembolism is low when the initial episode was provoked by a reversible major risk factor (surgery): 3 months of anticoagulation is sufficient. Conversely, the risk is high when venous thromboembolism was unprovoked or associated with persistent risk factor (cancer): 6 months or more prolonged anticoagulation is necessary. After this first estimation, the duration of anticoagulation may be modulated according to the presence or absence of certain additional risk factors (major thrombophilia, chronic pulmonary hypertension, massive pulmonary embolism): 6 months if pulmonary embolism was provoked and 12 to 24 months if pulmonary embolism was unprovoked. If the risk of anticoagulant-related bleeding is high, the duration of anticoagulation should be shortened (3 months if pulmonary embolism was provoked and 3 to 6 months if it was unprovoked). Lastly, if pulmonary embolism occurred in association with cancer, anticoagulation should be conducted for 6 months or more if the cancer is active or treatment is on going. Despite an increasing knowledge of the risk factors for recurrent venous thromboembolism, a number of issues remain unresolved. Randomised trials comparing different durations of anticoagulation are needed.