Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
Pol Arch Intern Med. 2020 Jun 6;130(6):529-538. doi: 10.20452/pamw.15225. Epub 2020 Mar 3.
The incidence of venous thromboembolism (VTE) and VTE‑related morbidity and mortality increase with advancing age. Over the past decade, substantial advances in the treatment of VTE have been achieved. Most notably, direct oral anticoagulants (DOACs) were introduced, which offer simple treatment regimens across a broad spectrum of patients with VTE and have become the first‑choice anticoagulants in many individuals in this population. Even though elderly patients are underrepresented in clinical trials, the extrapolation of overall study results to the elderly subpopulation can be considered justified regarding acute VTE treatment and the choice of anticoagulant agent. In the elderly, DOACs are not only associated with a lower bleeding risk but they also appear to be even more efficacious than vitamin K antagonists in preventing recurrent VTE during the acute treatment period. Determining the optimal treatment duration is the most challenging aspect of VTE management in elderly patients. The risk of bleeding increases with advancing age, and several risk factors for recurrent VTE after stopping anticoagulation are also more frequent in the elderly. Clinical decision rules estimating the risk of recurrent VTE and bleeding have limited utility in elderly patients. Shared decision making considering patients' preferences and values is therefore crucial to help determine individual treatment duration in these patients.
静脉血栓栓塞症（VTE）的发病率以及与 VTE 相关的发病率和死亡率会随年龄增长而增加。在过去十年中，VTE 的治疗取得了重大进展。最值得注意的是，直接口服抗凝剂（DOAC）的出现，为 VTE 患者提供了广泛谱的简单治疗方案，并且已成为该人群中许多个体的首选抗凝剂。尽管临床试验中老年人的代表性不足，但在急性 VTE 治疗和抗凝药物选择方面，将总体研究结果外推至老年亚人群是合理的。在老年人中，DOAC 不仅出血风险较低，而且在急性治疗期间预防复发性 VTE 的效果似乎比维生素 K 拮抗剂更有效。确定最佳治疗持续时间是老年患者 VTE 管理中最具挑战性的方面。出血风险随年龄增长而增加，并且停止抗凝后复发性 VTE 的几个危险因素在老年人中也更为常见。用于估计复发性 VTE 和出血风险的临床决策规则在老年患者中的实用性有限。因此，考虑患者偏好和价值观的共同决策对于帮助确定这些患者的个体化治疗持续时间至关重要。
