澳大利亚和新西兰血栓与止血学会关于静脉血栓栓塞症诊断和管理的新指南

摘要(中文译文)

静脉血栓栓塞症（VTE），包括深静脉血栓形成（DVT）和肺栓塞（PE），是第三大常见心血管疾病，全球每年估计有超过1000万人患病。它是一种慢性且易复发的疾病。VTE的症状不具特异性，一旦考虑该诊断即应积极寻求确诊。VTE治疗的主要手段是抗凝治疗，少数患者需要额外干预。该领域的一个专家工作组近期代表澳大利亚和新西兰血栓与止血学会（www.thanz.org.au/resources/thanz-guidelines）完成了DVT和PE诊断与管理的循证指南。VTE的诊断应通过影像学检查确立；可通过临床预测规则联合D-二聚体检测予以排除。由已不存在的大手术或创伤所致的近端DVT或PE，应接受3个月抗凝治疗。无诱因或与暂时性（非手术性）危险因素相关的近端DVT或PE，应接受3~6个月抗凝治疗。由活动性癌症或抗磷脂综合征诱发的复发性（两次或以上）近端DVT或PE，应接受延长抗凝治疗。由已不存在的主要诱发因素所致的远端DVT，应接受6周抗凝治疗。对于继续接受延长抗凝治疗的患者，可处方治疗剂量或低剂量的直接口服抗凝药，在无禁忌证的情况下优于华法林。不建议常规进行易栓症检测。对于大面积（血流动力学不稳定）PE，应进行溶栓或合适的替代治疗。大多数急性VTE患者应接受Xa因子抑制剂治疗，并进行延长抗凝治疗的评估。

Abstract

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non-specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention. A working group of experts in the area recently completed an evidence-based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand (www.thanz.org.au/resources/thanz-guidelines). The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D-dimer testing. Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months. Proximal DVT or PE that is unprovoked or associated with a transient risk factor (non-surgical) should be treated with anticoagulant therapy for 3-6 months. Proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation. Distal DVT caused by a major provoking factor that is no longer present should be treated with anticoagulant therapy for 6 weeks. For patients continuing with extended anticoagulant therapy, either therapeutic or low dose direct oral anticoagulants can be prescribed and is preferred over warfarin in the absence of contraindications. Routine thrombophilia testing is not indicated. Thrombolysis or a suitable alternative is indicated for massive (haemodynamically unstable) PE. Most patients with acute VTE should be treated with a factor Xa inhibitor and be assessed for extended anticoagulation.

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