Division of Hospital Medicine, Center for Innovation and Improvement Science, University of California, San Diego, San Diego, California.
J Hosp Med. 2013 Oct;8(10):582-8. doi: 10.1002/jhm.2071. Epub 2013 Aug 27.
Hospital-associated nonsurgical venous thromboembolism (VTE) is an important problem addressed by new guidelines from the American College of Physicians (ACP) and American College of Chest Physicians (AT9).
Narrative review and critique.
Both guidelines discount asymptomatic VTE outcomes and caution against overprophylaxis, but have different methodologies and estimates of risk/benefit. Guideline complexity and lack of consensus on VTE risk assessment contribute to an implementation gap. Methods to estimate prophylaxis benefit have significant limitations because major trials included mostly screening-detected events. AT9 relies on a single Italian cohort study to conclude that those with a Padua score ≥4 have a very high VTE risk, whereas patients with a score <4 (60% of patients) have a very small risk. However, the cohort population has less comorbidity than US inpatients, and over 1% of patients with a score of 3 suffered pulmonary emboli. The ACP guideline does not endorse any risk-assessment model. AT9 includes the Padua model and Caprini point-based system for nonsurgical inpatients and surgical inpatients, respectively, but there is no evidence they are more effective than simpler risk-assessment models.
New VTE prevention guidelines provide varied guidance on important issues including risk assessment. If Padua is used, a threshold of 3, as well as 4, should be considered. Simpler VTE risk-assessment models may be superior to complicated point-based models in environments without sophisticated clinical decision support.
医院相关的非外科静脉血栓栓塞症（VTE）是美国医师学院（ACP）和美国胸科医师学会（ACCP）新指南关注的一个重要问题。
叙述性综述和评价。
这两个指南都不重视无症状 VTE 结局，并告诫不要过度预防，但它们的方法和风险/效益估计不同。指南的复杂性和 VTE 风险评估的共识缺乏导致了实施差距。预防措施效益的评估方法存在显著的局限性，因为主要试验大多包括筛查发现的事件。ACCP 指南依赖于一项意大利单一队列研究来得出结论，即那些 Padua 评分≥4 的患者 VTE 风险非常高，而评分<4（60%的患者）的患者风险非常小。然而，队列人群的合并症比美国住院患者少，评分 3 的患者中有超过 1%患有肺栓塞。ACP 指南不支持任何风险评估模型。ACCP 指南分别纳入了 Padua 模型和 Caprini 基于点的系统用于非外科住院患者和外科住院患者，但没有证据表明它们比更简单的风险评估模型更有效。
新的 VTE 预防指南就包括风险评估在内的重要问题提供了不同的指导。如果使用 Padua 模型，应考虑 3 分和 4 分的阈值。在没有复杂临床决策支持的环境中，更简单的 VTE 风险评估模型可能优于复杂的基于点的模型。
