Alikhan Raza, Cohen Alexander T
Arthur Bloom Haemophilia Centre and Haemostasis Laboratory, University Hospital of Wales, Heath Park, Cardiff, UK, CF14 4XW.
Cochrane Database Syst Rev. 2010 Feb 17(2):CD003747. doi: 10.1002/14651858.CD003747.pub3.
Venous thromboembolic disease has been extensively studied in surgical patients. The benefit of thromboprophylaxis is now generally accepted, but it is medical patients who make up the greater proportion of the hospital population. Medical patients differ from surgical patients with regard to their health and the pathogenesis of thromboembolism and the impact that preventative measures can have. The extensive experience from thromboprophylaxis studies in surgical patients is therefore not necessarily applicable to non-surgical patients.
To determine the effectiveness and safety of heparin thromboprophylaxis in general medical patients.
The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched 24 April 2009) and the Cochrane Central Register of Controlled Trials in The Cochrane Library (last searched Issue 2, 2009)We handsearched meeting abstracts, and consulted with colleagues and investigators as well as the manufacturers of the various LMWH preparations to identify unpublished or missed studies.
Randomised controlled trials comparing unfractionated heparin (UFH) or low molecular weight heparin (LMWH) with placebo or no treatment, or comparing UFH with LMWH.
One author identified possible trials, and the other author confirmed eligibility for inclusion in the review. Both authors extracted the data. Disagreements were resolved by discussion. We performed the meta-analysis as a fixed-effect model with relative risks.
A significant risk reduction in deep vein thrombosis (DVT) by 60% (relative risk (RR) 0.40; 95% confidence interval CI 0.31 to 0.53; P < 0.00001) and pulmonary embolism (PE) by 42% (RR 0.58; 95% CI 0.43 to 0.80; P = 0.0007) was observed with heparin compared with placebo or no treatment. However, heparin resulted in a significant increase in major haemorrhage (RR 2.18; 95% CI 1.28 to 3.72; P = 0.004) and minor haemorrhage (RR 1.74; 95% CI 1.26 to 2.41; P = 0.0008). There was no statistically significant difference in efficacy between LMWH and UFH. There was a statistically significant 72% risk reduction in major bleeding when LMWH was compared with UFH (RR 0.28; 95% CI 0.10 to 0.78; P = 0.02).
AUTHORS' CONCLUSIONS: The data from this review support the use of heparin thromboprophylaixs in medical patients presenting with an acute medical illness. Although the analysis found no significant difference in efficacy between LMWH and UFH, it did note differences in the incidence of DVT and clinical PE with a significantly reduced risk of bleeding in favour of LMWH.
静脉血栓栓塞性疾病在外科手术患者中已得到广泛研究。血栓预防的益处目前已得到普遍认可，但内科患者占医院患者总数的比例更大。内科患者在健康状况、血栓形成的发病机制以及预防措施可能产生的影响方面与外科手术患者有所不同。因此，外科手术患者血栓预防研究的丰富经验不一定适用于非手术患者。
确定普通内科患者中肝素血栓预防的有效性和安全性。
Cochrane外周血管疾病小组检索了其专业注册库（最近一次检索时间为2009年4月24日）以及Cochrane图书馆中的Cochrane对照试验中心注册库（最近一次检索时间为2009年第2期）。我们手工检索了会议摘要，并咨询了同事、研究者以及各种低分子肝素制剂的制造商，以识别未发表或遗漏的研究。
比较普通肝素（UFH）或低分子肝素（LMWH）与安慰剂或不治疗，或比较UFH与LMWH的随机对照试验。
一位作者确定可能的试验，另一位作者确认纳入综述的资格。两位作者提取数据。分歧通过讨论解决。我们采用固定效应模型和相对风险进行荟萃分析。
与安慰剂或不治疗相比，肝素使深静脉血栓形成（DVT）风险显著降低60%（相对风险（RR）0.40；95%置信区间（CI）0.31至0.53；P<0.00001），肺栓塞（PE）风险显著降低42%（RR 0.58；95%CI 0.43至0.80；P = 0.0007）。然而，肝素导致大出血（RR 2.18；95%CI 1.28至3.72；P = 0.004）和小出血（RR 1.74；95%CI 1.26至2.41；P = 0.0008）显著增加。LMWH和UFH在疗效上无统计学显著差异。与UFH相比，LMWH时大出血风险显著降低72%（RR 0.28；95%CI 0.10至0.78；P = 0.02）。
本综述的数据支持在患有急性内科疾病的内科患者中使用肝素进行血栓预防。虽然分析发现LMWH和UFH在疗效上无显著差异，但确实注意到DVT和临床PE发生率存在差异，LMWH的出血风险显著降低。
