Weitz Jeffrey I, Prandoni Paolo, Verhamme Peter
Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada.
Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua, Italy.
TH Open. 2020 Dec 23;4(4):e446-e456. doi: 10.1055/s-0040-1721735. eCollection 2020 Oct.
The need for extended venous thromboembolism (VTE) treatment beyond 3 to 6 months is usually determined by balancing the risk of recurrence if treatment is stopped against the risk of bleeding from continuing treatment. The risk of recurrence, and in turn the decision to extend, can be determined through the nature of the index event. Patients with VTE provoked by surgery or trauma (major transient risk factors) are recommended to receive 3 months of anticoagulation therapy because their risk of recurrence is low, whereas patients with VTE provoked by a major persistent risk factor, such as cancer, or those considered to have "unprovoked" VTE, are recommended to receive an extended duration of therapy based on an established high risk of recurrence. Nonetheless, recent evidence and new guidance identify that this approach fails to consider patients with risk factors classed as minor transient (e.g., impaired mobility and pregnancy) or minor persistent (e.g., inflammatory bowel disease and congestive heart disease). Indeed, the risk of recurrence with respect to VTE provoked by minor persistent risk factors has been demonstrated to be not dissimilar to that of VTE without identifiable risk factors. This review provides an overview of the available data on the risk of recurrence according to the underlying cause of VTE, a critical evaluation of evidence from clinical studies on the available anticoagulants for extended VTE treatment, models of risk prediction for recurrent VTE and bleeding, and guidance on how to apply the evidence in practice.
对于静脉血栓栓塞症（VTE）患者，超过3至6个月的延长治疗需求通常取决于权衡停止治疗后的复发风险与继续治疗的出血风险。复发风险以及是否延长治疗的决定可通过首发事件的性质来确定。因手术或创伤引发VTE的患者（主要是短暂性风险因素），建议接受3个月的抗凝治疗，因为其复发风险较低；而因主要持续性风险因素（如癌症）引发VTE的患者，或被认为是“不明原因”VTE的患者，鉴于其既定的高复发风险，建议接受延长疗程的治疗。尽管如此，最近的证据和新指南表明，这种方法没有考虑到具有轻微短暂性风险因素（如活动能力受损和妊娠）或轻微持续性风险因素（如炎症性肠病和充血性心力衰竭）的患者。事实上，由轻微持续性风险因素引发的VTE的复发风险已被证明与无明确风险因素的VTE的复发风险并无差异。本综述概述了根据VTE潜在病因得出的复发风险的现有数据，对关于延长VTE治疗的可用抗凝剂的临床研究证据、复发性VTE和出血的风险预测模型进行了批判性评估，并就如何在实践中应用这些证据提供了指导。
