Iñurrieta Amaia, Pedrajas José María, Núñez Manuel Jesús, López-Jiménez Luciano, Velo-García Alba, García Juan Carlos, Lecumberri Ramón, Jiménez David, Pons Isaac, Monreal Manuel
Department of Internal Medicine, Hospital Clínico San Carlos, Madrid, Spain.
Department of Internal Medicine, Complejo Hospitalario de Pontevedra, Pontevedra, Spain.
TH Open. 2018 Dec 10;2(4):e428-e436. doi: 10.1055/s-0038-1676359. eCollection 2018 Oct.
The ideal duration of anticoagulant therapy in elderly patients with unprovoked venous thromboembolism (VTE) has not been consistently evaluated. We used the RIETE ( egistro nformatizado nfermedad rombo mbólica) registry to compare the rate and severity of pulmonary embolism (PE) recurrences versus major bleeding beyond the third month of anticoagulation in patients >75 years with a first episode of unprovoked VTE. As of September 2017, 7,830 patients were recruited: 5,058 (65%) presented with PE and 2,772 with proximal deep vein thrombosis (DVT). During anticoagulant therapy beyond the third month (median, 113 days), 44 patients developed PE recurrences, 36 developed DVT recurrences, 101 had major bleeding, and 241 died (3 died of recurrent PE and 19 of bleeding). The rate of major bleeding was twofold higher than the rate of PE recurrences (2.05 [95% confidence interval, CI: 1.68-2.48] vs. 0.90 [95% CI: 0.66-1.19] events per 100 patient-years) and the rate of fatal bleeding exceeded the rate of fatal PE events (0.38 [95% CI: 0.24-0.58] vs. 0.06 [95% CI: 0.02-0.16] deaths per 100 patient-years). On multivariable analysis, patients who had bled during the first 3 months (hazard ratio [HR]: 4.32; 95% CI: 1.58-11.8) or with anemia at baseline (HR: 1.87; 95% CI: 1.24-2.81) were at increased risk for bleeding beyond the third month. Patients initially presenting with PE were at increased risk for PE recurrences (HR: 3.60; 95% CI: 1.28-10.1). Prolonging anticoagulation beyond the third month was associated with more bleeds than PE recurrences. Prior bleeding, anemia, and initial VTE presentation may help decide when to stop therapy.
老年特发性静脉血栓栓塞症（VTE）患者抗凝治疗的理想时长尚未得到一致评估。我们利用RIETE（静脉血栓形成疾病信息登记系统）登记库，比较了年龄大于75岁的首次特发性VTE患者抗凝治疗三个月后肺栓塞（PE）复发率及严重程度与严重出血情况。截至2017年9月，共招募了7830例患者：5058例（65%）为PE，2772例为近端深静脉血栓形成（DVT）。在抗凝治疗三个月后（中位数为113天），44例患者出现PE复发，36例出现DVT复发，101例发生严重出血，241例死亡（3例死于复发性PE，19例死于出血）。严重出血发生率比PE复发率高出两倍（每100患者年2.05例[95%置信区间，CI：1.68 - 2.48] vs. 0.90例[95% CI：0.66 - 1.19]），致命性出血发生率超过致命性PE事件发生率（每100患者年0.38例[95% CI：0.24 - 0.58] vs. 0.06例[95% CI：0.02 - 0.16]）。多变量分析显示，在最初三个月内有出血情况的患者（风险比[HR]：4.32；95% CI：1.58 - 11.8）或基线时伴有贫血的患者（HR：1.87；95% CI：1.24 - 2.81）在三个月后出血风险增加。最初表现为PE的患者PE复发风险增加（HR：3.60；95% CI：1.28 - 10.1）。抗凝治疗超过三个月与更多出血事件相关，而非PE复发。既往出血、贫血及初始VTE表现可能有助于决定何时停止治疗。
