Ost David, Tepper Josh, Mihara Hanako, Lander Owen, Heinzer Raphael, Fein Alan
Center for Pulmonary and Critical Care Medicine, North Shore University Hospital, Manhasset, NY 11030, USA.
JAMA. 2005 Aug 10;294(6):706-15. doi: 10.1001/jama.294.6.706.
Patients with venous thromboembolism (VTE) are susceptible to recurrent events, but whether prolonging anticoagulation is warranted in patients with VTE remains controversial.
To review the available evidence and quantify the risks and benefits of extending the duration of anticoagulation in patients with VTE.
PubMed, EMBase Pharmacology, the Cochrane database, clinical trial Web sites, and a hand search of reference lists.
Included studies were randomized controlled trials with results published from 1969 through 2004 and evaluating the duration of anticoagulation in patients with VTE that measured recurrent VTE. Excluded studies were those enrolling only pure populations of high-risk patients. Two independent reviewers assessed each article for inclusion and exclusion criteria, with adjudication by a third reviewer in cases of disagreement. Fifteen of 67 studies were included in the analysis.
Two independent reviewers performed data extraction using a standardized form, with adjudication by the remainder of the investigators in cases of disagreement. Data regarding recurrent VTE, major bleeding, person-time at risk, and study quality were extracted.
If patients in the long-term therapy group remained receiving anticoagulation, the risk of recurrent VTE with long- vs short-term therapy was reduced (weighted incidence rate, 0.020 vs 0.126 events/person-year; rate difference, -0.106 [95% confidence interval {CI}, -0.145 to -0.067]; P<.001; pooled incidence rate ratio [IRR], 0.21 [95% CI, 0.14 to 0.31]; P<.001). If anticoagulation in the long-term therapy group was discontinued, the risk reduction was less pronounced (weighted incidence rate, 0.052 vs 0.072 events/person-year; rate difference, -0.020 [95% CI, -0.039 to -0.001]; P = .04; pooled IRR, 0.69 [95% CI, 0.53 to 0.91]; P = .009). The risk of major bleeding with long- vs short-term therapy was similar (weighted incidence rate, 0.011 vs 0.006 events/person-year; rate difference, 0.005 [95% CI, -0.002 to 0.011]; P = .14; pooled IRR, 1.80 [95% CI, 0.72 to 4.51]; P = .21).
Patients who receive extended anticoagulation are protected from recurrent VTE while receiving long-term therapy. The clinical benefit is maintained after anticoagulation is discontinued, but the magnitude of the benefit is less pronounced.
静脉血栓栓塞症（VTE）患者易复发，但对于VTE患者是否需要延长抗凝治疗仍存在争议。
回顾现有证据并量化VTE患者延长抗凝治疗时间的风险和获益。
PubMed、EMBase药理学数据库、Cochrane数据库、临床试验网站，并手工检索参考文献列表。
纳入的研究为1969年至2004年发表结果的随机对照试验，评估VTE患者的抗凝治疗时间，并测量复发性VTE。排除的研究为仅纳入高危患者纯人群的研究。两名独立评审员根据纳入和排除标准评估每篇文章，如有分歧则由第三名评审员裁决。67项研究中有15项纳入分析。
两名独立评审员使用标准化表格进行数据提取，如有分歧则由其余研究人员裁决。提取有关复发性VTE、大出血、风险人时和研究质量的数据。
如果长期治疗组患者持续接受抗凝治疗，长期治疗与短期治疗相比，复发性VTE的风险降低（加权发病率，0.020 vs 0.126事件/人年；率差，-0.106 [95%置信区间{CI}，-0.145至-0.067]；P<.001；合并发病率比[IRR]，0.21 [95% CI，0.14至0.31]；P<.001）。如果长期治疗组停止抗凝治疗，风险降低不太明显（加权发病率，0.052 vs 0.072事件/人年；率差，-0.020 [9�% CI，-0.039至-0.001]；P = .04；合并IRR，0.69 [95% CI，0.53至0.91]；P = .009）。长期治疗与短期治疗相比，大出血风险相似（加权发病率，0.011 vs 0.006事件/人年；率差，0.005 [95% CI，-0.002至0.011]；P = .14；合并IRR，1.80 [95% CI，0.72至⁴.51]；P = .21）。
接受延长抗凝治疗的患者在长期治疗期间可预防复发性VTE。停止抗凝治疗后临床获益仍可维持，但获益程度不太明显。
