接受治疗和未接受治疗的患者中，癌症相关性偶发性肺栓塞患者复发性静脉血栓栓塞和大出血的风险：926例患者的汇总分析
Risk of recurrent venous thromboembolism and major hemorrhage in cancer-associated incidental pulmonary embolism among treated and untreated patients: a pooled analysis of 926 patients.
作者信息
van der Hulle T, den Exter P L, Planquette B, Meyer G, Soler S, Monreal M, Jiménez D, Portillo A K, O'Connell C, Liebman H A, Shteinberg M, Adir Y, Tiseo M, Bersanelli M, Abdel-Razeq H N, Mansour A H, Donnelly O G, Radhakrishna G, Ramasamy S, Bozas G, Maraveyas A, Shinagare A B, Hatabu H, Nishino M, Huisman M V, Klok F A
机构信息
Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
Department of Respiratory and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, Université Paris Descartes, INSERM U 965, Paris, France.
出版信息
J Thromb Haemost. 2016 Jan;14(1):105-13. doi: 10.1111/jth.13172. Epub 2016 Jan 11.
UNLABELLED
ESSENTIALS: We performed a pooled analysis of 926 patients with cancer-associated incidental pulmonary embolism (IPE). Vitamin K antagonists (VKA) are associated with a higher risk of major hemorrhage. Recurrence risk is comparable after subsegmental and more proximally localized IPE. Our results support low molecular weight heparins over VKA and similar management of subsegmental IPE.
BACKGROUND
Incidental pulmonary embolism (IPE) is defined as pulmonary embolism (PE) diagnosed on computed tomography scanning not performed for suspected PE. IPE has been estimated to occur in 3.1% of all cancer patients and is a growing challenge for clinicians and patients. Nevertheless, knowledge about the treatment and prognosis of cancer-associated IPE is scarce. We aimed to provide the best available evidence on IPE management.
METHODS
Incidence rates of symptomatic recurrent venous thromboembolism (VTE), major hemorrhage, and mortality during 6-month follow-up were pooled using individual patient data from studies identified by a systematic literature search. Subgroup analyses based on cancer stage, thrombus localization, and management were performed.
RESULTS
In 926 cancer patients with IPE from 11 cohorts, weighted pooled 6-month risks of recurrent VTE, major hemorrhage and mortality were 5.8% (95% confidence interval [CI] 3.7-8.3%), 4.7% (95% CI 3.0-6.8%), and 37% (95% CI 28-47%). VTE recurrence risk was comparable under low molecular weight heparins (LMWH) and vitamin K antagonists (VKAs) (6.2% vs. 6.4%; hazard ratio [HR] 0.9; 95% CI 0.3-3.1), while 12% in untreated patients (HR 2.6; 95% CI 0.91-7.3). Risk of major hemorrhage was higher under VKAs than under LMWH (13% vs. 3.9%; HR 3.9; 95% CI 1.6-10). VTE recurrence risk was comparable in patients with an subsegmental IPE and those with a more proximally localized IPE (HR 1.1; 95% CI 0.50-2.4).
CONCLUSION
These results support the current recommendation to anticoagulate cancer-associated IPE with LMWH and argue against different management of subsegmental IPE.
未标注
要点：我们对926例癌症相关偶发性肺栓塞（IPE）患者进行了汇总分析。维生素K拮抗剂（VKA）与大出血风险较高相关。亚段性和更近端定位的IPE复发风险相当。我们的结果支持低分子量肝素优于VKA，并支持对亚段性IPE进行类似的管理。
背景
偶发性肺栓塞（IPE）定义为在并非因疑似肺栓塞而进行的计算机断层扫描上诊断出的肺栓塞（PE）。据估计，IPE在所有癌症患者中的发生率为3.1%，对临床医生和患者来说是一个日益严峻的挑战。然而，关于癌症相关IPE的治疗和预后的知识却很匮乏。我们旨在提供关于IPE管理的最佳现有证据。
方法
使用通过系统文献检索确定的研究中的个体患者数据，汇总6个月随访期间有症状的复发性静脉血栓栓塞（VTE）、大出血和死亡率的发生率。进行了基于癌症分期、血栓定位和管理的亚组分析。
结果
在来自11个队列的926例患有IPE的癌症患者中，复发性VTE、大出血和死亡率的加权汇总6个月风险分别为5.8%（95%置信区间[CI]3.7 - 8.3%）、4.7%（95%CI 3.0 - 6.8%）和37%（95%CI 28 - 47%）。低分子量肝素（LMWH）和维生素K拮抗剂（VKA）治疗下的VTE复发风险相当（6.2%对6.4%；风险比[HR]0.9；95%CI 0.3 - 3.1），而未治疗患者的复发风险为12%（HR 2.6；95%CI 0.91 - 7.3）。VKA治疗下的大出血风险高于LMWH（13%对3.9%；HR 3.9；95%CI 1.6 - 10）。亚段性IPE患者和更近端定位的IPE患者的VTE复发风险相当（HR 1.1；95%CI 0.50 - 2.4）。
结论
这些结果支持目前用LMWH对癌症相关IPE进行抗凝的建议，并反对对亚段性IPE采用不同的管理方法。
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