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Acute treatment of venous thromboembolism.

静脉血栓栓塞的急性治疗。

  • 影响因子:7.27
  • DOI:10.1182/blood.2019001881
  • 作者列表:"Becattini C","Agnelli G
  • 发表时间:2020-01-30
Abstract

:All patients with venous thromboembolism (VTE) should receive anticoagulant treatment in the absence of absolute contraindications. Initial anticoagulant treatment is crucial for reducing mortality, preventing early recurrences, and improving long-term outcome. Treatment and patient disposition should be tailored to the severity of clinical presentation, to comorbidities, and to the potential to receive appropriate care in the outpatient setting. Direct oral anticoagulants (DOACs) used in fixed doses without laboratory monitoring are the agents of choice for the treatment of acute VTE in the majority of patients. In comparison with conventional anticoagulation (parenteral anticoagulants followed by vitamin K antagonists), these agents showed improved safety (relative risk [RR] of major bleeding, 0.61; 95% confidence interval [CI], 0.45-0.83) with a similar risk of recurrence (RR, 0.90; 95% CI, 0.77-1.06). Vitamin K antagonists or low molecular weight heparins are still alternatives to DOACs for the treatment of VTE in specific patient categories such as those with severe renal failure or antiphospholipid syndrome, or cancer, respectively. In addition to therapeutic anticoagulation, probably less than 10% of patients require reperfusion by thrombolysis or interventional treatments; those patients are hemodynamically unstable with acute pulmonary embolism, and a minority of them have proximal limb-threatening deep vein thrombosis (DVT). The choice of treatment should be driven by the combination of evidence from clinical trials and by local expertise. The majority of patients with acute DVT and a proportion of selected hemodynamically stable patients with acute pulmonary embolism can be safely managed as outpatients.

摘要

: 所有静脉血栓栓塞 (VTE) 患者应在没有绝对禁忌症的情况下接受抗凝治疗。初始抗凝治疗对于降低死亡率、预防早期复发和改善长期预后至关重要。治疗和患者处置应根据临床表现的严重程度、合并症以及在门诊接受适当护理的可能性进行调整。在没有实验室监测的情况下以固定剂量使用的直接口服抗凝剂 (DOACs) 是大多数患者治疗急性 VTE 的首选药物。与常规抗凝 (胃肠外抗凝药,然后是维生素k 拮抗剂) 相比,这些药物显示安全性提高 (大出血的相对风险 [RR],0.61; 95% 置信区间 [CI], 0.45-0.83),复发风险相似 (RR,0.90; 95% CI,0.77-1.06)。维生素 K 拮抗剂或低分子量肝素仍然是 DOACs 的替代药物,分别用于治疗特定患者类别的 VTE,如严重肾衰竭或抗磷脂综合征或癌症。除了治疗性抗凝之外,可能不到 10% 的患者需要溶栓或介入治疗的再灌注; 这些患者血流动力学不稳定,伴有急性肺栓塞, 其中少数患者有近端肢体威胁的深静脉血栓形成 (DVT)。治疗的选择应该由来自临床试验的证据和当地专业知识的结合来驱动。大多数急性 DVT 患者和部分选定的血流动力学稳定的急性肺栓塞患者可以作为门诊患者安全管理。

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