Santos Sónia Martins, Cunha Susana, Baptista Rui, Monteiro Sílvia, Monteiro Pedro, Gonçalves Francisco, Pêgo Mariano
Serviço de Medicina 2, Centro Hospitalar de Leiria, Hospital de Leiria, Leiria, Portugal.
Serviço de Cardiologia A, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
Rev Port Cardiol. 2017 Nov;36(11):801-806. doi: 10.1016/j.repc.2017.01.010. Epub 2017 Nov 8.
Intermediate-high risk pulmonary embolism (IHR-PE) has a poor prognosis, but is under-represented in trials of direct oral anticoagulants (DOACs) in venous thromboembolic disease (VTE). We aimed to assess whether the administration of DOACs was equivalent to the conventional (CONV) treatment of low-molecular weight heparin bridged with warfarin for treating IHR-PE.
We conducted a retrospective cohort study including 59 consecutive patients admitted with IHR-PE and followed for up to three months after discharge. Two groups were created based on the anticoagulant strategy: CONV (n=35) and DOAC (n=24). The efficacy endpoints were death, recurrent PE, estimated pulmonary artery systolic pressure (PASP), right ventricular systolic function (RVSF) at discharge, and length of stay; the safety endpoint was major bleeding.
The two groups were similar regarding demographics, PE etiology and markers of clinical severity. There were four in-hospital deaths in the CONV group and none in the DOAC group. No recurrent PE or major bleeding event was recorded in either group. At discharge, neither PASP nor RVSF was different between the groups. Patients in the DOAC group were discharged 1.7 days earlier on average than patients in the CONV group (4.7±2.4 vs. 3.0±1.5 days, p=0.002).
The adoption of a DOAC treatment strategy in this real-world cohort of IHR-PE patients was associated with similar efficacy and safety to the CONV approach. The fact that monitoring of anticoagulation effect was unnecessary probably led to the significant reduction in length of stay.
中高危肺栓塞（IHR-PE）预后较差，但在静脉血栓栓塞性疾病（VTE）的直接口服抗凝剂（DOACs）试验中代表性不足。我们旨在评估DOACs的给药是否等同于低分子量肝素桥接华法林治疗IHR-PE的传统（CONV）治疗。
我们进行了一项回顾性队列研究，纳入59例连续收治的IHR-PE患者，并在出院后随访长达三个月。根据抗凝策略分为两组：CONV组（n=35）和DOAC组（n=24）。疗效终点为死亡、复发性肺栓塞、出院时估计的肺动脉收缩压（PASP）、右心室收缩功能（RVSF）和住院时间；安全终点为大出血。
两组在人口统计学、肺栓塞病因和临床严重程度标志物方面相似。CONV组有4例住院死亡，DOAC组无死亡。两组均未记录到复发性肺栓塞或大出血事件。出院时，两组的PASP和RVSF均无差异。DOAC组患者平均出院时间比CONV组早1.7天（4.7±2.4天对3.0±1.5天，p=0.002）。
在这个真实世界的IHR-PE患者队列中采用DOAC治疗策略与CONV方法具有相似的疗效和安全性。无需监测抗凝效果这一事实可能导致住院时间显著缩短。
