Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.
Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.
Eur J Vasc Endovasc Surg. 2019 May;57(5):685-701. doi: 10.1016/j.ejvs.2018.11.004.
OBJECTIVE/BACKGROUND: The aim was to review the relative efficacy and safety of anticoagulation for managing venous thromboembolism (VTE) in patients with cancer.
A systematic review and meta-analysis was carried out. On 17 May 2018 the MEDLINE and Scopus databases were searched for randomised controlled trials (RCTs). Eligible RCTs had to be performed in patients with cancer exclusively or to report results on a subset of patients with cancer. The main study outcomes (efficacy/recurrent VTE and safety/bleeding events) were expressed as risk ratios (RR) with a 95% confidence interval (CI). The quality of evidence was assessed following the GRADE method.
Twenty-three RCTs with 6980 patients were identified. Low molecular weight heparins (LMWHs) were more effective than vitamin K antagonists (VKAs) in preventing recurrent VTE (RR 0.58, 95% CI 0.45-0.75) and deep vein thrombosis (RR 0.44, 95% CI 0.29-0.69) but not pulmonary embolism (PE), bleeding, or overall mortality. Direct oral anticoagulants (DOACs) were more effective than VKAs in preventing recurrent VTE (RR 0.65, 95% CI 0.45-0.95) but not DVT, PE, overall mortality, or bleeding. However, anti-Xa DOACs were more effective (RR for VTE 0.64, 95% CI 0.42-0.97) and caused less bleeding than VKAs, although major bleeding was reduced only with DOACs not requiring initial parenteral anticoagulation (RR 0.45, 95% CI 0.21-0.97). In a direct comparison, DOACs were more effective than LMWHs in preventing VTE recurrence (RR 0.64, 95% CI 0.45-0.90) but caused more major bleeding (RR 1.75, 95% CI 1.10-2.77), with no difference in fatal bleeding and overall mortality. Quality of evidence, where sufficient, was mostly moderate or high.
Compared with VKAs, LMWHs and DOACs are more effective in treating VTE, but the former caused less bleeding. DOACs are more effective than LMWHs in preventing VTE recurrence but may carry a higher risk of major bleeding, pending additional information by ongoing trials.
目的/背景：本研究旨在评估抗凝治疗在癌症合并静脉血栓栓塞症（VTE）患者中的相对疗效和安全性。
进行了系统评价和荟萃分析。于 2018 年 5 月 17 日检索了 MEDLINE 和 Scopus 数据库中的随机对照试验（RCT）。合格的 RCT 必须仅在癌症患者中进行，或报告癌症患者亚组的结果。主要研究结局（有效性/复发性 VTE 和安全性/出血事件）用风险比（RR）及其 95%置信区间（CI）表示。根据 GRADE 方法评估证据质量。
共纳入 23 项 RCT 共计 6980 例患者。与维生素 K 拮抗剂（VKA）相比，低分子肝素（LMWH）更能有效预防复发性 VTE（RR 0.58，95%CI 0.45-0.75）和深静脉血栓形成（RR 0.44，95%CI 0.29-0.69），但对肺栓塞（PE）、出血或总体死亡率无影响。与 VKA 相比，直接口服抗凝剂（DOAC）更能有效预防复发性 VTE（RR 0.65，95%CI 0.45-0.95），但对 DVT、PE、总体死亡率或出血无影响。然而，抗 Xa DOAC 比 VKA 更有效（RR 为 VTE 0.64，95%CI 0.42-0.97）且出血更少，尽管只有不需要初始静脉抗凝的 DOAC 才能减少大出血（RR 0.45，95%CI 0.21-0.97）。在直接比较中，DOAC 比 LMWH 更能有效预防 VTE 复发（RR 0.64，95%CI 0.45-0.90），但出血更多（RR 1.75，95%CI 1.10-2.77），致命性出血和总体死亡率无差异。证据质量在足够的情况下，主要为中至高。
与 VKA 相比，LMWH 和 DOAC 治疗 VTE 更有效，但前者出血更少。DOAC 比 LMWH 更能有效预防 VTE 复发，但可能有更高的大出血风险，尚待正在进行的试验提供更多信息。
