Department of Medicine, McMaster University, Hamilton, ON, Canada.
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Am J Med. 2018 Apr;131(4):430-437. doi: 10.1016/j.amjmed.2017.11.042. Epub 2017 Dec 20.
Low-molecular-weight heparin (LMWH) is the treatment of choice in cancer patients with venous thromboembolism. However, data on continuing LMWH treatment beyond 6 months remain scanty.
We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to compare the rate of venous thromboembolism recurrences and major bleeding appearing beyond the first 6 months of anticoagulant therapy in cancer patients with venous thromboembolism, according to therapy with LMWH or vitamin K antagonists (VKA). We performed a propensity score-matched cohort study.
After propensity matching, 482 cancer patients continued to receive LMWH and 482 switched to VKA. During the course of anticoagulant therapy (mean 275.5 days), 57 patients developed venous thrombosis recurrences (recurrent pulmonary embolism 26, recurrent deep vein thrombosis 29, both 2), 28 had major bleeding, 38 had nonmajor bleeding, and 129 died. No patient died of recurrent venous thrombosis, and 5 patients died of bleeding (2 were on LMWH, 3 on VKA). Patients who continued with LMWH had a similar rate of deep vein thrombosis recurrences (relative risk [RR] 1.41; 95% confidence interval [CI], 0.68-2.93), pulmonary embolism recurrences (RR 0.73; 95% CI, 0.34-1.58), major bleeding (RR 0.96; 95% CI, 0.51-1.79), or nonmajor bleeding (RR 1.15; 95% CI, 0.55-2.40), compared with those who switched to VKA, but a higher mortality rate (RR 1.58; 95% CI, 1.13-2.20).
In cancer patients with venous thromboembolism who completed 6 months of LMWH therapy, switching to VKA was associated with a similar risk of venous thrombosis recurrences or bleeding when compared with patients who continued LMWH.
低分子肝素（LMWH）是癌症合并静脉血栓栓塞患者的首选治疗方法。然而，关于抗凝治疗超过 6 个月的 LMWH 持续治疗的数据仍然很少。
我们使用 RIETE（血栓栓塞登记处）登记处，根据癌症合并静脉血栓栓塞患者接受 LMWH 或维生素 K 拮抗剂（VKA）治疗，比较抗凝治疗超过前 6 个月时静脉血栓栓塞复发和主要出血的发生率。我们进行了倾向评分匹配队列研究。
经过倾向评分匹配后，482 例癌症患者继续接受 LMWH 治疗，482 例患者转为 VKA 治疗。在抗凝治疗过程中（平均 275.5 天），57 例患者发生静脉血栓栓塞复发（复发性肺栓塞 26 例，复发性深静脉血栓形成 29 例，两者均 2 例），28 例发生大出血，38 例发生非大出血，129 例死亡。无患者死于静脉血栓栓塞复发，5 例患者死于出血（2 例在 LMWH 组，3 例在 VKA 组）。继续使用 LMWH 的患者深静脉血栓栓塞复发率（相对风险 [RR] 1.41；95%置信区间 [CI]，0.68-2.93）、肺栓塞复发率（RR 0.73；95% CI，0.34-1.58）、大出血率（RR 0.96；95% CI，0.51-1.79）或非大出血率（RR 1.15；95% CI，0.55-2.40）与转为 VKA 的患者相似，但死亡率更高（RR 1.58；95% CI，1.13-2.20）。
在完成 6 个月 LMWH 治疗的癌症合并静脉血栓栓塞患者中，与继续使用 LMWH 的患者相比，转为 VKA 治疗与静脉血栓栓塞复发或出血风险相似。
