静脉血栓栓塞症。
Venous thromboembolism.
机构信息
School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
出版信息
Lancet. 2021 Jul 3;398(10294):64-77. doi: 10.1016/S0140-6736(20)32658-1. Epub 2021 May 10.
Venous thromboembolism, comprising both deep vein thrombosis and pulmonary embolism, is a chronic illness that affects nearly 10 million people every year worldwide. Strong provoking risk factors for venous thromboembolism include major surgery and active cancer, but most events are unprovoked. Diagnosis requires a sequential work-up that combines assessment of clinical pretest probability for venous thromboembolism using a clinical score (eg, Wells score), D-dimer testing, and imaging. Venous thromboembolism can be considered excluded in patients with both a non-high clinical pretest probability and normal D-dimer concentrations. When required, ultrasonography should be done for a suspected deep vein thrombosis and CT or ventilation-perfusion scintigraphy for a suspected pulmonary embolism. Direct oral anticoagulants (DOACs) are the first-line treatment for almost all patients with venous thromboembolism (including those with cancer). After completing 3-6 months of initial treatment, anticoagulation can be discontinued in patients with venous thromboembolism provoked by a major transient risk factor. Patients whose long-term risk of recurrent venous thromboembolism outweighs the long-term risk of major bleeding, such as those with active cancer or men with unprovoked venous thromboembolism, should receive indefinite anticoagulant treatment. Pharmacological venous thromboembolism prophylaxis is generally warranted in patients undergoing major orthopaedic or cancer surgery. Ongoing research is focused on improving diagnostic strategies for suspected deep vein thrombosis, comparing different DOACs, developing safer anticoagulants, and further individualising approaches for the prevention and management of venous thromboembolism.
静脉血栓栓塞症,包括深静脉血栓形成和肺栓塞,是一种影响全球近 1000 万人的慢性疾病。静脉血栓栓塞症的强烈诱发危险因素包括大手术和活动性癌症,但大多数事件是无诱因的。诊断需要一个连续的工作流程,该流程结合使用临床评分(例如 Wells 评分)、D-二聚体检测和影像学评估对静脉血栓栓塞症的临床前测试概率进行评估。对于具有非高临床前测试概率和正常 D-二聚体浓度的患者,可以认为排除了静脉血栓栓塞症。当需要时,应进行超声检查以怀疑深静脉血栓形成,进行 CT 或通气灌注闪烁扫描以怀疑肺栓塞。直接口服抗凝剂(DOAC)是几乎所有静脉血栓栓塞症患者(包括癌症患者)的一线治疗药物。在完成初始治疗的 3-6 个月后,如果静脉血栓栓塞症是由重大短暂风险因素引起的,可以停止抗凝治疗。对于那些复发静脉血栓栓塞症的长期风险超过大出血的长期风险的患者,例如活动性癌症或无诱因静脉血栓栓塞症的男性,应接受无限期抗凝治疗。对于接受重大骨科或癌症手术的患者,一般需要进行药物性静脉血栓栓塞症预防。目前的研究重点是改善疑似深静脉血栓形成的诊断策略,比较不同的 DOAC,开发更安全的抗凝剂,并进一步针对静脉血栓栓塞症的预防和管理进行个体化治疗。