Caprini Joseph A, Tapson Victor F, Hyers Thomas M, Waldo Albert L, Wittkowsky Ann K, Friedman Richard, Colgan Kevin J, Shillington Alicia C
Evanston Northwestern Healthcare and Feinberg School of Medicine, Northwestern University, Chicago, Ill, USA.
J Vasc Surg. 2005 Oct;42(4):726-33. doi: 10.1016/j.jvs.2005.05.053.
To assess the treatment of venous thromboembolism (VTE) in hospitalized patients enrolled in a national, multicenter database.
This was a retrospective, cohort study that randomly selected VTE patients from 38 academic/teaching, community, and Veterans Administration (VA) hospitals. The study included a physician survey component. The patients selected were those treated between January 2002 and June 2003 who had an ICD-9-CM code for pulmonary embolus (PE), deep vein thrombosis (DVT), or pregnancy-related PE or DVT.
The study included 939 patients: 52.7% with DVT, 28.4% with PE, and 18.8% with PE and DVT. Mean age was 59.5 years. Risk factors included obesity (body mass index > 30) in 30.1%, history of VTE in 28.0%, malignancy in 27.4%, surgery in 21.1%, and immobility in 18.5%. Only 56.1% of patients were treated with low-molecular-weight heparin (LMWH). Bridging from LMWH or unfractionated heparin (UFH) to warfarin was completed during hospitalization in 486 (68.6%), but only 246 (50.6%) had an international normalized ratio (INR) > or = 2 for 48 hours before discontinuation of the injectable anticoagulant. Length of stay in patients discharged on bridge therapy was 4.0 +/- 3.7 days vs 8.1 +/- 5.8 days for patients discharged on warfarin therapy (P < .001). Ninety-two (10.1%) patients were discharged with neither oral nor injectable anticoagulation and had a mean duration of treatment of only 10.6 +/- 16.2 days. Of 245 physicians surveyed from participating hospitals, 84% and 53%, respectively, indicated that LMWH was their preferred agent for treatment of DVT and treatment of PE. With regard to warfarin, 30% did not believe it was necessary to have a therapeutic INR for > or = 2 days before discontinuing LMWH or UFH, and 27% responded that it was necessary to keep DVT patients in the hospital until they were therapeutic.
In this cross-section of United States hospitals, lower than anticipated use of LMWH, insufficient bridging from UFH or LMWH to warfarin, and continuation of anticoagulation after hospitalization were all problems discovered with the treatment of VTE. Physician knowledge, attitudes, and beliefs are partially responsible for the gap between actual practice and international guidelines. These results suggest that hospitals should evaluate their adherence to international VTE treatment guidelines and develop strategies to optimize antithrombotic therapy.
评估纳入一个全国性多中心数据库的住院患者静脉血栓栓塞症（VTE）的治疗情况。
这是一项回顾性队列研究，从38家学术/教学医院、社区医院和退伍军人管理局（VA）医院中随机选取VTE患者。该研究包括一项医师调查部分。入选患者为2002年1月至2003年6月期间接受治疗且具有肺栓塞（PE）、深静脉血栓形成（DVT）或妊娠相关PE或DVT的国际疾病分类第九版临床修订本（ICD-9-CM）编码的患者。
该研究纳入939例患者：52.7%患有DVT，28.4%患有PE，18.8%同时患有PE和DVT。平均年龄为59.5岁。危险因素包括肥胖（体重指数>30）占30.1%，VTE病史占28.0%，恶性肿瘤占27.4%，手术占21.1%，活动减少占18.5%。仅56.1%的患者接受了低分子量肝素（LMWH）治疗。486例（68.6%）患者在住院期间完成了从LMWH或普通肝素（UFH）过渡到华法林的治疗，但在停用注射用抗凝剂前仅有246例（50.6%）的国际标准化比值（INR）≥2且持续48小时。接受桥接治疗出院患者的住院时间为4.0±3.7天，而接受华法林治疗出院患者的住院时间为8.1±5.8天（P<0.001）。92例（10.1%）患者出院时既未接受口服抗凝治疗也未接受注射抗凝治疗，平均治疗时间仅为10.6±16.2天。在参与研究的医院接受调查的245名医师中，分别有84%和53%表示LMWH是他们治疗DVT和PE的首选药物。关于华法林，30%的医师认为在停用LMWH或UFH前没有必要使INR达到治疗水平≥2天，27%的医师回答有必要让DVT患者住院直至达到治疗水平。
在美国医院的这个横断面研究中，发现VTE治疗存在LMWH使用低于预期、UFH或LMWH向华法林过渡不足以及出院后继续抗凝等问题。医师的知识、态度和观念部分导致了实际治疗与国际指南之间的差距。这些结果表明医院应评估其对国际VTE治疗指南的遵循情况，并制定优化抗栓治疗的策略。
