澳大利亚和新西兰血栓与止血学会静脉血栓栓塞症诊断和管理新指南。
New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism.
机构信息
Alfred Health, Melbourne, VIC.
Monash University, Melbourne, VIC.
出版信息
Med J Aust. 2019 Mar;210(5):227-235. doi: 10.5694/mja2.50004. Epub 2019 Feb 10.
INTRODUCTION
Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non-specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention. A working group of experts in the area recently completed an evidence-based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand (www.thanz.org.au/resources/thanz-guidelines).
MAIN RECOMMENDATIONS
The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D-dimer testing. Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months. Proximal DVT or PE that is unprovoked or associated with a transient risk factor (non-surgical) should be treated with anticoagulant therapy for 3-6 months. Proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation. Distal DVT caused by a major provoking factor that is no longer present should be treated with anticoagulant therapy for 6 weeks. For patients continuing with extended anticoagulant therapy, either therapeutic or low dose direct oral anticoagulants can be prescribed and is preferred over warfarin in the absence of contraindications. Routine thrombophilia testing is not indicated. Thrombolysis or a suitable alternative is indicated for massive (haemodynamically unstable) PE.
CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE
Most patients with acute VTE should be treated with a factor Xa inhibitor and be assessed for extended anticoagulation.
简介
静脉血栓栓塞症（VTE）包括深静脉血栓形成（DVT）和肺栓塞（PE），是第三大常见心血管疾病，全球每年估计有超过 1000 万人患有该病。它是一种慢性和复发性疾病。VTE 的症状是非特异性的，一旦被认为有这种病，就应该积极寻求诊断。VTE 的主要治疗方法是抗凝，只有少数患者需要额外的干预。一个专家工作组最近代表澳大利亚和新西兰血栓与止血学会（www.thanz.org.au/resources/thanz-guidelines）完成了一项针对 DVT 和 PE 的诊断和管理的循证指南。
主要建议
VTE 的诊断应通过影像学检查确定；通过使用临床预测规则结合 D-二聚体检测，可排除 VTE 的可能性。由重大手术或创伤引起的、现已不再存在的近端 DVT 或 PE 应使用抗凝治疗 3 个月。无诱因或伴有短暂风险因素（非手术）的近端 DVT 或 PE 应使用抗凝治疗 3-6 个月。由活动性癌症或抗磷脂综合征引起的、反复发作（两次或以上）的近端 DVT 应接受延长抗凝治疗。由不再存在的重大诱发因素引起的远端 DVT 应使用抗凝治疗 6 周。对于继续接受延长抗凝治疗的患者，可以开处方使用治疗剂量或低剂量直接口服抗凝剂，在没有禁忌症的情况下，优于华法林。常规血栓形成倾向检测不适用。对于大面积（血流动力学不稳定）PE，建议溶栓或其他合适的替代方法。
由于该指南的改变，管理方式发生了变化：大多数急性 VTE 患者应使用 Xa 因子抑制剂治疗，并评估是否需要延长抗凝治疗。
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