Schafer Andrew I, Levine Mark N, Konkle Barbara A, Kearon Clive
University of Pennsylvania School of Medicine, Department of Medicine, Philadelphia, PA 19104, USA.
Hematology Am Soc Hematol Educ Program. 2003:520-39. doi: 10.1182/asheducation-2003.1.520.
Hematologists are increasingly involved in the diagnosis and management of patients with venous and arterial thromboembolic disorders. There have been major advances in recent years in our understanding of the central role of hypercoagulability in the pathogenesis of thrombosis. This has led to new approaches to the diagnosis of patients at risk for thrombosis and the development of more rational antithrombotic strategies. In Section I, Dr. Andrew Schafer reviews current concepts of acquired and inherited hypercoagulable states. It is now recognized that most, if not all, patients with venous thromboembolism have a genetic basis for the disorder ("thrombophilia"). The level of lifelong, baseline hypercoagulability in any individual may be determined by the type(s) and number of thrombophilia(s) that are inherited. Clinical episodes of thrombosis are precipitated by acquired thrombogenic triggers, which may be overt (e.g., pregnancy) or subclinical. In Section II, Dr. Mark Levine discusses the complex problem of thrombosis in patients with cancer. The goals of treating acute venous thromboembolism in cancer patients are to prevent recurrence, minimize the risk of anticoagulant-induced bleeding, and improve quality of life. New developments have improved treatment of venous thromboembolism in these patients, including outpatient therapy and secondary prevention with low-molecular-weight heparin. In Section III, Dr. Barbara Konkle reviews the diagnosis and management of thrombotic complications associated with pregnancy and hormonal therapy. Patient management is discussed based on data on thrombotic risks associated with hormonal treatment of infertility, pregnancy and the post-partum period in women with and without underlying thrombophilic risk factors. In Section IV, Dr. Clive Kearon discusses the management of anticoagulation before and after elective surgery. In the past, there has been no consensus on the perioperative management of anticoagulation for patients who require long-term warfarin therapy. This review considers the expected risks and benefits of different approaches to anticoagulation in patients who require warfarin because of atrial fibrillation, a mechanical heart valve, or a history of venous thromboembolism.
血液学家越来越多地参与到静脉和动脉血栓栓塞性疾病患者的诊断和管理中。近年来，我们对高凝状态在血栓形成发病机制中的核心作用的理解取得了重大进展。这导致了对血栓形成风险患者诊断的新方法以及更合理的抗血栓策略的发展。在第一部分，安德鲁·谢弗博士回顾了获得性和遗传性高凝状态的当前概念。现在人们认识到，大多数（如果不是全部）静脉血栓栓塞患者的疾病都有遗传基础（“易栓症”）。任何个体终身的基线高凝水平可能由所遗传的易栓症类型和数量决定。血栓形成的临床发作是由获得性血栓形成触发因素引发的，这些因素可能是明显的（如怀孕）或亚临床的。在第二部分，马克·莱文博士讨论了癌症患者血栓形成的复杂问题。治疗癌症患者急性静脉血栓栓塞的目标是预防复发、将抗凝剂引起出血的风险降至最低，并改善生活质量。新的进展改善了这些患者静脉血栓栓塞的治疗方法，包括门诊治疗和使用低分子肝素进行二级预防。在第三部分，芭芭拉·康克尔博士回顾了与妊娠和激素治疗相关的血栓形成并发症的诊断和管理。根据有无潜在易栓风险因素的女性在不育症、妊娠和产后激素治疗相关血栓形成风险的数据，讨论了患者管理问题。在第四部分，克莱夫·卡隆博士讨论了择期手术前后的抗凝管理。过去对于需要长期华法林治疗的患者围手术期抗凝管理没有达成共识。这篇综述考虑了因心房颤动、机械心脏瓣膜或静脉血栓栓塞病史而需要华法林治疗的患者采用不同抗凝方法的预期风险和益处。
