延长抗凝治疗在静脉血栓栓塞症中的应用：系统评价和荟萃分析。
Extended Anticoagulation for VTE: A Systematic Review and Meta-Analysis.
机构信息
Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Québec City, QC, Canada.
Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Québec City, QC, Canada; Department of Medicine, Université Laval, Québec City, QC, Canada; Pulmonary Hypertension Research Group.
出版信息
Chest. 2019 Jun;155(6):1199-1216. doi: 10.1016/j.chest.2019.02.402.
BACKGROUND
The efficacy and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) during extended anticoagulation for a VTE remains largely unknown, especially in terms of potential survival benefit. The goal of this study was to assess the effects of VKAs and DOACs on overall mortality and VTE-related mortality, as well as VTE recurrence and safety.
METHODS
PubMed, EMBASE, and the Cochrane Library were searched from January 1990 through September 2018 for randomized controlled trials evaluating the effect of extended anticoagulants as secondary prevention for VTE compared with placebo. The primary outcome was the specific effects of standard-intensity VKAs and DOACs on overall mortality.
RESULTS
Sixteen studies (12,458 patients) were included. DOACs were associated with a reduction in overall (risk ratio [RR], 0.48; 95% CI, 0.27-0.86; P = .01) and VTE-related (RR, 0.36; 95% CI, 0.15-0.89; P = .03) mortality, whereas VKAs were not (P > .50). Although VKAs and DOACs similarly prevented recurrent VTE, only VKAs were associated with an increased risk of major bleeding (RR, 2.67; 95% CI, 1.28-5.60; P < .01), resulting in an improved net clinical benefit for DOACs (RR, 0.25 [95% CI, 0.16-0.39; P < .01] vs 0.46 [95% CI, 0.30-0.72; P < .01]; P = .05).
CONCLUSIONS
DOACs for extended anticoagulation were associated with a significant reduction in overall mortality compared with observation alone.
TRIAL REGISTRY
PROSPERO; No.: CRD42018088739; URL: https://www.crd.york.ac.uk/prospero/.
背景
在 VTE 的延长抗凝治疗中，直接口服抗凝剂（DOACs）和维生素 K 拮抗剂（VKAs）的疗效和安全性在很大程度上仍然未知，特别是在潜在的生存获益方面。本研究的目的是评估 VKAs 和 DOACs 对总死亡率和与 VTE 相关的死亡率以及 VTE 复发和安全性的影响。
方法
从 1990 年 1 月到 2018 年 9 月，通过 PubMed、EMBASE 和 Cochrane 图书馆检索了评估与安慰剂相比，延长抗凝剂作为 VTE 二级预防对 VTE 复发的影响的随机对照试验。主要结局是标准强度 VKAs 和 DOACs 对总死亡率的具体影响。
结果
纳入了 16 项研究（12458 例患者）。DOACs 与降低总死亡率（风险比 [RR]，0.48；95%CI，0.27-0.86；P=0.01）和与 VTE 相关的死亡率（RR，0.36；95%CI，0.15-0.89；P=0.03）相关，而 VKAs 则没有（P>0.50）。尽管 VKAs 和 DOACs 同样预防了 VTE 的复发，但只有 VKAs 与大出血的风险增加相关（RR，2.67；95%CI，1.28-5.60；P<0.01），从而使 DOACs 的净临床获益得到改善（RR，0.25 [95%CI，0.16-0.39；P<0.01] 比 0.46 [95%CI，0.30-0.72；P<0.01]；P=0.05）。
结论
与单独观察相比，DOACs 用于延长抗凝治疗与总死亡率的显著降低相关。
试验注册
PROSPERO；编号：CRD42018088739；网址：https://www.crd.york.ac.uk/prospero/。
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