Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research, Northwell Health at Lenox Hill Hospital, New York, New York, United States.
Department of Medicine and Surgery, University of Insubria, Varese, Italy.
Thromb Haemost. 2020 Jun;120(6):924-936. doi: 10.1055/s-0040-1710326. Epub 2020 Jun 3.
Venous thromboembolism (VTE) remains a major cause of morbidity and mortality in hospitalized medically ill patients. These patients constitute a heterogeneous population, whose VTE risk is dependent upon the acute medical illness, immobility status, and patient-specific risk factors that have been incorporated into individualized VTE risk assessment models. Randomized placebo-controlled trials (RCTs) have shown both efficacy and net clinical benefit of in-hospital thromboprophylaxis, which is supported by guideline recommendations. The data for extended posthospital discharge thromboprophylaxis are more nuanced. RCTs comparing standardized duration low-molecular weight heparin versus extended duration direct oral anticoagulants, such as betrixaban and rivaroxaban, have shown efficacy and net clinical benefit in select groups of high VTE and low-bleed risk populations of hospitalized medically ill patients. These oral agents are now approved for both in-hospital and extended thromboprophylaxis. However, the most recent guidelines do not recommend routine use of these agents for extended thromboprophylaxis. Longitudinal studies in medically ill patients have shown that the majority of VTE events occur in the posthospital discharge setting within 6 weeks of hospitalization. This, coupled with the short hospital length-of-stay and lack of routine postdischarge thromboprophylaxis in U.S. health care settings, has dampened quality improvement efforts aimed at reducing hospital-acquired VTE. The aim of this multidisciplinary document is to provide an evidence-based framework to guide clinicians in assessing VTE and bleeding risk in hospitalized medically ill patients using an individualized, risk-adapted, and patient-centered approach, with the aim of providing clinical pathways toward the use of appropriate type and duration of available thromboprophylactic agents.
静脉血栓栓塞症（VTE）仍然是住院治疗的内科疾病患者发病率和死亡率的主要原因。这些患者构成了一个异质人群，他们的 VTE 风险取决于急性内科疾病、活动受限状态以及已纳入个体化 VTE 风险评估模型的患者特定危险因素。随机安慰剂对照试验（RCT）已显示出住院期间血栓预防的疗效和净临床获益，这得到了指南建议的支持。延长住院后出院血栓预防的数据更为复杂。比较标准化疗程低分子量肝素与延长疗程直接口服抗凝剂（如贝曲西班和利伐沙班）的 RCT 已显示出在选择的高 VTE 和低出血风险的住院内科疾病患者群体中具有疗效和净临床获益。这些口服药物现已获准用于住院期间和延长的血栓预防。然而，最近的指南不建议常规使用这些药物进行延长的血栓预防。内科疾病患者的纵向研究表明，大多数 VTE 事件发生在住院后 6 周内的出院后环境中。这一点，再加上美国医疗保健环境中住院时间短和缺乏常规出院后血栓预防，削弱了旨在减少医院获得性 VTE 的质量改进工作。这份多学科文件的目的是提供一个循证框架，指导临床医生使用个体化、风险适应和以患者为中心的方法评估住院治疗的内科疾病患者的 VTE 和出血风险，旨在提供使用适当类型和持续时间的可用血栓预防药物的临床途径。
