Hillis Christopher M, Crowther Mark A
Mark Crowther, MD, MSc, FRCPC, Rm L208, 50 Charlton Ave East, Hamilton, ON, Canada L8N 4A6, E-mail:
Thromb Haemost. 2015 Jun;113(6):1193-202. doi: 10.1160/TH14-12-1036. Epub 2015 May 7.
The acute phase of venous thromboembolism (VTE) treatment focuses on the prompt and safe initiation of full-dose anticoagulation to decrease morbidity and mortality. Immediate management consists of resuscitation, supportive care, and thrombolysis for patients with haemodynamically significant pulmonary embolism (PE) or limb-threatening deep-vein thrombosis (DVT). Patients with contraindications to anticoagulants are considered for vena cava filters. Disposition for the acute treatment of VTE is then considered based on published risk scores and the patient's social status, as the first seven days carries the highest risk for VTE recurrence, extension and bleeding due to anticoagulation. Next, a review of: immediate and long-term bleeding risk, comorbidities (i. e. active cancer, renal failure, obesity, thrombophilia), medications, patient preference, VTE location and potential for pregnancy should be undertaken. This will help determine the most suitable anticoagulant for immediate treatment. The non-vitamin K antagonist oral anticoagulants (NOACs), including the factor Xa inhibitors apixaban, edoxaban and rivaroxaban as well as the direct-thrombin inhibitor dabigatran, are increasing the convenience of and options available for VTE treatment. Current options for immediate treatment include low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), fondaparinux, apixaban, or rivaroxaban. LMWH or UFH may be continued as monotherapy or transitioned to treatment with a VKA, dabigatran or edoxaban. This review describes the upfront treatment of VTE and the evolving role of NOACs in the contemporary management of VTE.
静脉血栓栓塞症（VTE）治疗的急性期重点在于迅速且安全地启动全剂量抗凝治疗，以降低发病率和死亡率。对于有血流动力学显著改变的肺栓塞（PE）或危及肢体的深静脉血栓形成（DVT）患者，即刻处理包括复苏、支持治疗和溶栓治疗。对抗凝剂有禁忌证的患者考虑植入腔静脉滤器。然后根据已公布的风险评分和患者的社会状况来考虑VTE急性期治疗的处置方式，因为最初七天VTE复发、扩展以及抗凝导致出血的风险最高。接下来，应评估即刻和长期出血风险、合并症（如活动性癌症、肾衰竭、肥胖症、易栓症）、药物、患者偏好、VTE部位以及妊娠可能性。这将有助于确定最适合即刻治疗的抗凝剂。非维生素K拮抗剂口服抗凝药（NOACs），包括Xa因子抑制剂阿哌沙班、依度沙班和利伐沙班以及直接凝血酶抑制剂达比加群，增加了VTE治疗的便利性和可选择方案。目前即刻治疗的选择包括低分子肝素（LMWH）、普通肝素（UFH）、磺达肝癸钠、阿哌沙班或利伐沙班。LMWH或UFH可继续作为单一疗法，或过渡为使用维生素K拮抗剂、达比加群或依度沙班进行治疗。本综述描述了VTE的初始治疗以及NOACs在当代VTE管理中不断演变的作用。
