Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia.
Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Semin Thromb Hemost. 2019 Mar;45(2):187-195. doi: 10.1055/s-0038-1676320. Epub 2018 Dec 19.
The highest risk of adverse events for patients with acute venous thromboembolism (VTE) is during the early anticoagulation period. However, no established model exists for early clinical monitoring of patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). The authors' aim was to evaluate the utility of a nurse-led pathway to minimize adverse events in acute VTE patients starting on rivaroxaban. The rivaroxaban VTE treatment pathway is a prospective cohort study of consecutive patients with objectively confirmed VTE between July 2015 and May 2017. Primary outcome was the proportion of patients identified at major risk of adverse events (bleeding or recurrent VTE). Secondary outcomes were rates of interventions, major or clinically relevant nonmajor bleeding (CRNMB), recurrent VTE, and all-cause mortality at 90 days. Among 304 participants, 5% ( = 15) were identified to be at major and 9% ( = 28) at possible risk for adverse events. Appropriate interventions to prevent harm were required in 40 patients. Rates of major bleeding, CRNMB, recurrence, and all-cause mortality were 0.3% (95% confidence interval [CI]: 0.1-1.8), 7.2% (95% CI: 4.8-10.7), 1.0 (95% CI: 0.3-2.9), and 1.6% (95% CI: 0.7-3.8), respectively. In conclusion, following discharge of acute VTE patients, a nurse-led pathway identified one in seven (14%) patients at major or possible risk of adverse events. Preemptive interventions to reduce harm translated into the low rates of bleeding and recurrence. The authors' experience highlights the feasibility and importance of a structured clinical surveillance pathway for acute VTE patients initiating NOAC therapy.
急性静脉血栓栓塞症（VTE）患者发生不良事件的风险最高是在抗凝治疗早期。然而，目前还没有建立针对非维生素 K 拮抗剂口服抗凝剂（NOAC）治疗患者的早期临床监测模型。作者旨在评估基于护士主导的路径对利伐沙班治疗急性 VTE 患者的不良事件发生风险的降低作用。利伐沙班 VTE 治疗路径是一项前瞻性队列研究，纳入 2015 年 7 月至 2017 年 5 月期间经客观检查确诊的 VTE 连续患者。主要结局为确定大出血或复发性 VTE 高风险患者的比例。次要结局为干预措施、大出血或临床相关非大出血（CRNMB）、复发性 VTE 和 90 天全因死亡率的发生率。在 304 名患者中，5%（15 名）患者被确定为有大出血高风险，9%（28 名）为有大出血或复发性 VTE 可能风险。需要进行适当干预以预防伤害的患者有 40 名。大出血、CRNMB、复发性 VTE 和全因死亡率的发生率分别为 0.3%（95%可信区间[CI]：0.1-1.8）、7.2%（95% CI：4.8-10.7）、1.0%（95% CI：0.3-2.9）和 1.6%（95% CI：0.7-3.8）。总之，在急性 VTE 患者出院后，基于护士主导的路径可识别出 7 分之 1（14%）有大出血或复发性 VTE 高或可能风险的患者。采取预防措施减少伤害的发生率转化为较低的出血和复发率。作者的经验强调了针对开始接受 NOAC 治疗的急性 VTE 患者构建结构化临床监测路径的可行性和重要性。
