Department of Vascular Surgery, University of Maryland, Baltimore, MD; Surgery Service, VA Medical Center, Baltimore, MD.
Department of Vascular Surgery, University of Maryland, Baltimore, MD.
J Vasc Surg Venous Lymphat Disord. 2022 Nov;10(6):1401-1409.e7. doi: 10.1016/j.jvsv.2022.05.003. Epub 2022 Aug 2.
Hospital-acquired venous thromboembolism (VTE, including pulmonary embolism [PE] and deep vein thrombosis [DVT]) is a preventable cause of hospital death. The Caprini risk assessment model (RAM) is one of the most commonly used tools to assess VTE risk. The RAM is operationalized in clinical practice by grouping several risk scores into VTE risk categories that drive decisions on prophylaxis. A correlation between increasing Caprini scores and rising VTE risk is well-established. We assessed whether the increasing VTE risk categories assigned on the basis of recommended score ranges also correlate with increasing VTE risk.
We conducted a systematic review of articles that used the Caprini RAM to assign VTE risk categories and that reported corresponding VTE rates. A Medline and EMBASE search retrieved 895 articles, of which 57 fulfilled inclusion criteria.
Forty-eight (84%) of the articles were cohort studies, 7 (12%) were case-control studies, and 2 (4%) were cross-sectional studies. The populations varied from postsurgical to medical patients. There was variability in the number of VTE risk categories assigned by individual studies (6 used 5 risk categories, 37 used 4, 11 used 3, and 3 used 2), and in the cutoff scores defining the risk categories (scores from 0 alone to 0-10 for the low-risk category; from ≥5 to ≥10 for high risk). The VTE rates reported for similar risk categories also varied across studies (0%-12.3% in the low-risk category; 0%-40% for high risk). The Caprini RAM is designed to assess composite VTE risk; however, two studies reported PE or DVT rates alone, and many of the other studies did not specify the types of DVTs analyzed. The Caprini RAM predicts VTE at 30 days after assessment; however, only 17 studies measured outcomes at 30 days; the remaining studies had either shorter or longer follow-ups (0-180 days).
The usefulness of the Caprini RAM is limited by heterogeneity in its implementation across centers. The score-derived VTE risk categorization has significant variability in the number of risk categories being used, the cutpoints used to define the risk categories, the outcome being measured, and the follow-up duration. This factor leads to similar risk categories being associated with different VTE rates, which impacts the clinical and research implications of the results. To enhance generalizability, there is a need for studies that validate the RAM in a broad population of medical and surgical patients, identify standardized risk categories, define risk of DVT and PE as distinct end points, and measure outcomes at standardized follow-up time points.
医院获得性静脉血栓栓塞症（VTE，包括肺栓塞[PE]和深静脉血栓形成[DVT]）是医院死亡的可预防原因。卡普里尼风险评估模型（RAM）是评估 VTE 风险最常用的工具之一。RAM 通过将几个风险评分分组为 VTE 风险类别来在临床实践中实施，这些类别可驱动预防决策。卡普里尼评分的增加与 VTE 风险的增加之间存在相关性已得到充分证实。我们评估了基于推荐评分范围分配的风险类别增加是否与 VTE 风险增加相关。
我们对使用卡普里尼 RAM 分配 VTE 风险类别并报告相应 VTE 发生率的文章进行了系统评价。对 Medline 和 EMBASE 进行了检索，共检索到 895 篇文章，其中 57 篇符合纳入标准。
48 篇（84%）文章为队列研究，7 篇（12%）为病例对照研究，2 篇（4%）为横断面研究。研究人群从术后患者到内科患者不等。个体研究分配的 VTE 风险类别数量存在差异（6 项研究使用 5 个风险类别，37 项研究使用 4 个，11 项研究使用 3 个，3 项研究使用 2 个），并且风险类别的截止分数也存在差异（低风险类别为 0 分，0-10 分；高风险类别为 5 分及以上，10 分及以上）。类似风险类别的 VTE 发生率也因研究而异（低风险类别为 0%-12.3%；高风险类别为 0%-40%）。卡普里尼 RAM 旨在评估复合 VTE 风险；但是，有两项研究仅报告了 PE 或 DVT 发生率，许多其他研究未具体说明分析的 DVT 类型。卡普里尼 RAM 预测评估后 30 天的 VTE；但是，只有 17 项研究在 30 天内测量了结果；其余研究的随访时间更短或更长（0-180 天）。
卡普里尼 RAM 的实用性受到其在各中心实施的异质性的限制。基于评分的 VTE 风险分类在使用的风险类别数量、用于定义风险类别的截止分数、测量的结果以及随访持续时间方面存在很大差异。这一因素导致相似的风险类别与不同的 VTE 发生率相关，从而影响了研究结果的临床和研究意义。为了提高通用性，需要在广泛的内科和外科患者群体中对 RAM 进行验证，确定标准化的风险类别，将 DVT 和 PE 的风险定义为不同的终点，并在标准化的随访时间点测量结果。
