静脉血栓栓塞症的确诊和治疗

Importance The incidence of deep vein thrombosis (DVT) in the lower extremities is 88-112/100,000 people/year and increases with age. Within 10 years after the initial episode, the recurrence rate of venous thromboembolism (VTE) is 20% to 36%.

Observation The researchers searched the PubMed and Cochrane databases for studies published between January 2015 and June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies.

Risk factors for VTE include: older age, malignancy (7.4% incidence after a median of 19 months), inflammatory diseases (VTE risk 4.7% in patients with rheumatoid arthritis and 2.5% in others), and hereditary thrombopathies (10-year incidence in Leiden factor V carriers 10.9%).

Confirmed Patients who present with signs or symptoms of lower extremity DVT, such as thigh or calf swelling (71%) or cramping or pulling discomfort (53%), should undergo a predictive probability assessment followed by D-dimer testing and venous ultrasound.

The combination of normal D-dimer levels (i.e., D-dimer <500 ng/mL) and a low predicted probability (i.e., Wells DVT score ≤1) excludes acute VTE.

Among patients with higher predictive probability, the incidence of D-dimer with a negative predictive value less than 500 ng/mL was 92%. Therefore, D-dimer cannot be used to rule out DVT without evaluating the predicted probability.

Within 3 to 6 months after a diagnosis of DVT, 25% to 50% of patients develop postthrombotic syndrome, which is defined as persistent symptoms, symptoms of chronic venous insufficiency, or both.

Treatment Catheter fibrinolytic therapy with or without mechanical thrombectomy is indicated for patients with femoral obstruction, severe symptoms, and low risk of bleeding.

Direct oral anticoagulants—rivaroxaban, apixaban, dabigatran, and edoxaban—are no less effective than warfarin (VTE recurrence or VTE-related death rates are 2.0% and 2.2%, respectively). Major bleeding occurred in 1.1% of patients taking direct oral anticoagulants and 1.8% of those receiving warfarin.

Conclusions and Relevance Increased knowledge of VTE risk factors and advances in anticoagulation technology have facilitated the clinical evaluation and treatment of patients with DVT. In terms of effectiveness, direct oral anticoagulants are not inferior to warfarin and have lower bleeding rates, but their cost limits their use in some patients.

References:

https://jamanetwork.com/journals/jama/article-abstract/2772499?resultClick=1