静脉血栓栓塞症危险因素.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,静脉血栓栓塞症的危险因素,北京医院呼吸与危重症医学科,许 小 毛,VTE=PTE+DVT,近,50%,腿部近端,DVT,的患者存在,PTE,约,80,PTE,患者有,DVT,（主要是无症状性,DVT,）,Pesavento R,et al.Minerva Cardioangiologica.1997;45:369,375,Girard P,et al.Chest.1999;116:903,908,栓子,迁移,血栓,同一疾病在不同阶段 不同部位的表现,流行病学特点,高发病率,高病死率,“,多发而少见,”,根源：高漏诊率,+,高误诊率,流行病学资料,Venous thrombosis-5 million pts yearly,Most caused by inadequate prophylaxis in hospitalized pts,10%suffer pulmonary embolism 500,000,1%of all hospitalized pts have PE,Contributes to 5-10%of all hospital deaths,125,000 deaths annually from PE,3rd most common cardiovascular cause of death(MI,CVA),Most deaths occur early,流行病学情况,发病率,美国：,DVT 1,，,PTE 0.5,，,年发病60万人,法国：年发病数,10,万,英国：住院,PTE 6.5,万/,年,6,深静脉血栓形成,-,肺血栓栓塞症：沉默的杀手,Pulmonary embolism Extrapolated Incidence,CW,N Engl J Med 2007;356:1438-44,警惕,VTE,的发生,VTE,高发病率,-,大部分住院患者都有,1,个或多个,VTE,危险因素,DVT,在许多住院患者中普遍存在,院内获得的,DVT,和,PE,通常无症状,识别,VTE,的危险因素并加以预防，可有效减少,VTE,的发生,PREVENTION IS KEY!,358 hospitals across 32 countries,only 39.5-58.5%patients at risk of VTE due to medical or surgical causes,respectively,received adequate prophylaxis.,26%of patients with undiagnosed and untreated PE will have a subsequent fatal embolic event,whereas another 26%will have a nonfatal recurrent embolic event,9,Cohen AT,Lancet 2008;371:387,394,Qaseem A,Ann Intern Med.2007;146:454-8,Virchow,s,三要素,Kyrle P A,Eichinger S Blood 2009;114:1138-1139,2009 by American Society of Hematology,Virchow,s,三要素,Defined VTE Risk Factors:(Virchow,s Triad),Venous stasis,-CHF,Immobility,Age 70,Travel,Obesity,Recent surgery(4 weeks)or hospitalization(6 mos),Venous Injury,-Prior DVT/PE,LE Trauma/Surgery,LE trauma or surgery-Very high(50+%),Major surgery-(5-8%),Hypercoaguability,-Cancer,Pregnancy,Nephrotic Syndrome,Hyperhomocysteinemia,Factor V Leyden mutation,Deficiency of Protein C/S or ATIII,Anti Phospholipid Ab,HITTS,Smoking,原发性：先天性,遗传变异引起,V,因子突变、蛋白,C,缺乏、蛋白,S,缺乏、抗凝血酶缺乏,继发性,:,后天获得性,骨折、创伤、手术、恶性肿瘤、口服避孕药、制动、高龄、吸烟、产妇、肾病综合征,危险因素,继发性危险因素,原发性危险因素,血栓形成,基因,-,环境相互作用,多数住院患者不止一种危险因素,The incidence of DVT correlates with the total number of risk factors,13,Anderson FA.Circulation 2003;107:I9,I16,临床危险因素识别,原发性：遗传性、先天性,继发性,环境和人群相关危险因素,外科手术或创伤相关危险因素,内科疾病相关危险因素,医源性干预措施相关因素,14,遗传性易栓症,抗凝蛋白缺乏,抗凝酶、蛋白,C,、蛋白,S,促凝蛋白增加,因子,V Leiden,凝血酶原基因突变,(G20210A),因子,VIII,IX,XI,水平增加,高加索人群遗传性易栓症的发病率,POPULATION PROTEIN C PROTEIN S ANTITHROMBIN FV G20210A,DEFICIENCY DEFICIENCY DEFICIENCY LEIDEN MUTATION,Normal,Consecutive,patients with,first VTE,Relative risk,of first VTE,0.3,3,10,0.3,3,10,0.04,1,25,4,16,4,2,5,2.5,DVT,患者中,FV Leiden,突变,APC-R,FV Leiden,DVT,control,DVT,control,Chinese Han nationality,Mainland,(Chu,1996),5/31,(16%),5/106,(4.7%),0/31,0/141,(Bai,2000),4/87,(4.6%),0/60,0/87,0/60,Taiwan,(Shen,1997),0/85,0/85,Chinese Kazak nationality,(Xing,2001),3/85,(3.5%),Japan,(Zama,1996),3/33,(9%),0/63,0/29,0/53,Europe,(Koster,1993),1,(den Heijer,1996),2,64/301,(21%),1,14/301,(5%),1,47/269,(17.5),2,7/269,(2.6%),2*,*,高加索人群中因子,V Leiden,突变的检出率,37%.,。,DVT,患者中凝血酶原基因,G20210A,突变,Prothrombin gene G20210A mutation,DVT,control,China,(Bai,2000),0/98,0/100,(He,2002),0/103,0/106,UK,(Cumming,1997),12/219,(5.5%),2/164,(1.2%),Holland,(Poort,1996),18%,1%,*,*,高加索人群中凝血酶原,G20210A,突变约占,2%,。,DVT,患者中抗凝蛋白缺乏,n,Deficient proteins,AT,PC,PS,Total,China,Mainland,(Bai,2000),87,5,(5.7%),8,(9.2%),13,(14.9%),26,(29.9%),Taiwan,(Shen,1997),85,3,(3.5%),16,(18.8%),28,(32.9%),47,(55.3%),Hong kong,(Liu,1994),52,5,(9.6%),9,(17.3%),10,(19.2%),24,(46.1%),Japan,(Suehisa,2001,113,2,(1.8%),9,(8.0%),20,(17.7%),31,(27.4%),Europe,(den Heijer,1996),269,10,(3.7%),15,(5.6%),7,(2.6%),32,(11.9%),抗凝蛋白,缺乏,其他,/,未明,APC-R,(Genetic defect?),APC-R,(FV Leiden),中国汉族人群,高加索人群,其他,/,未明,抗凝蛋白,缺乏,何时怀疑遗传性易栓症,VTE,家族史,发病年龄,70,岁,妊娠期和产褥期,肥胖,24,长时间制动引起下肢静脉血液淤积，饮水减少导致血液粘稠度增加,活动减少、肌张力减低、疾病增加、血管内皮功能减弱、下肢静脉回,流障碍、多种凝血因子活性增强,Incidence of VTE by sex and age,Parker C et al.BMJ 2010;341:bmj.c4245,British Journal of HaematologyVolume 139,Issue 2,pages 289-296,25 SEP 2007 DOI:10.1111/j.1365-2141.2007.06780.x of VTE by obesity,The risk of venous thrombosis:obesity and travel,MEGA study,overall 2 fold increase in risk,Cannegieter SC et al.PLOS Medicine 2006;3(8):1258-1264.,预防,-ACCP9,版指南,长途旅行者,对于有,VTE,危险因素的旅行者（既往,VTE,病史、近期创伤或手术史、肿瘤、妊娠、应用雌激素、高龄、活动不便、重度肥胖、或已知易栓症者），建议旅行期间经常活动、做腓肠肌运动或尽可能坐过道的座位（,2C,级）,，或,/,和,建议应用膝下梯度弹力袜,GCS,，维持踝部压力,15-30mmHg,之间,(2C,级,),。,28,外科手术或创伤相关危险因素,麻醉时间,30,分钟,髋、膝关节置换术,泌尿系统手术,神经外科手术,妇产科手术,严重创伤,骨折、脊髓损伤、头颅损伤,29,手术对组织、血管壁的损伤导致凝血系统激活，麻醉、体外循环造成血流缓慢、输血引起血液粘稠度增加,住院患者发生,DVT,的风险,Patient Group DVT Prevalence%,Medical patients:10,20,General surgery:15,40,Major gynecologic surgery:15,40,Major urologic surgery:15,40,Neurosurgery:15,40,Stroke:20,50,Hip or knee arthroplasty:40,60,Major trauma:40,80,Critical care patients:10,80,骨科大手术后,VTE,发生率较高,术式,DVT(%),PE(%),总发生率,近端发生率,总发生率,致命性,%,THR,42-57,18-36,0.9-28,0.1-2.0,TKR,41-85,5-22,1.5-10,0.1-1.7,髋骨骨折,46-60,23-30,3-11,0.3-7.5,参考文献,:,静脉血栓栓塞（,VTE,，,venous thromboembolism,）的预防，第,8,版,ACCP,指南,.Chest 2008;133:381-453,中国,3,个中心,马来西亚,1,个中心,台湾,4,个中心,南韩,5,个中心,菲律宾,3,个中心,泰国,1,个中心,印度尼西亚,2,个中心,AIDA,研究：,7,个国家,19,个中心进行的研究，发表于,2005,年,每个国家地区入组的病例数,中国,51,12.5,印度尼西亚,21,5.2,韩国,122,30.0,马来西亚,30,7.4,菲律宾,60,14.7,台湾省,83,20.4,泰国,40,9.8,总例数,407,DVT,发病率,43.2%,10.2%,4.4%,%DVT,(N=295),AIDA:,不同类型的骨科手术后均会发生,DVT,总,DVT(%),58.1%,25.6%,42.0%,Piovella et al.J Thromb Haemost 2005,60.0,76.5,84.0,57.0,11.3,6.0,2.7,19.1,事件发生率,%,35.5,普外手术,THR,TKR,髋部骨折,0.0,64.3,45.0,40.0,6.9,50.0,36.0,亚洲研究,西方研究,手术后,DVT,的发生率,0,40,60,80,100,20,Geerts et al.Chest 2004;,Leizorovicz et al.Int J Angiol 2004;Piovella et al.J Thromb Haemost 2005,骨科大手术患者,VTE,的危险分度,危险度,判断指标,低度危险,手术时间,45,40,岁,无危险因素,中度危险,手术时间,45,有危险因素,手术时间,45,40,岁,无危险因素,高度危险,手术时间,45,60,岁 有危险因素,手术时间,45,4060,岁,有危险因素,极 高 危,骨科大手术 重度创伤 脊髓损伤,手术时间,45,40,岁,有多项危险因素,预防,-ACCP 9,版指南,对于进行重大骨科手术患者，建议血栓预防措施延长至术后,35,天，而不仅仅是,10-14,天（,2B,级）。,对于住院期间的重大骨科手术患者，建议抗血栓药物和,IPCD,联合应用（,2C,级）。,38,内科疾病相关危险因素,心功能不全、急性心梗,COPD,、,ARDS,、间质性肺疾病,肾病综合征,恶性肿瘤,急性感染,结缔组织疾病,内科疾病急性期住院患者,VTE,发生较一般人群增加,8,倍,39,肿瘤与,VTE,40,41,预防,-ACCP 9,版指南,内科,急症,和危重症,患者,对于血栓形成风险较高的内科急症患者，推荐预防性抗凝治疗（,1B,级）。,对于血栓形成风险较高，但目前正出血或有较高出血风险的内科急症患者，建议选择机械性预防措施（,2C,级）。当出血风险减少，但,VTE,风险持续存在时，建议应用药物预防替代机械性预防（,2B,级）,对于开始血栓预防治疗的内科急症患者，疗程不应超过患者卧床或住院时间（,2B,级）。,42,肿瘤患者,对于无,VTE,危险因素（既往血栓栓塞病史、卧床、激素治疗、服用血管再生抑制剂及镇静剂）的患者，不建议常规预防血栓,治疗,（,2B,级）,。,对于有,VTE,危险因素且出血风险较低的实体肿瘤患者，建议应用,LMWH,或,LDUH,预防血栓（,2B,级）。,对于留置中心静脉导管的肿瘤患者，不建议常规预防血栓,治疗,（,2B,级）,。,43,医源性干预措施相关因素,药源性,抗肿瘤药,口服避孕药,2-3/,万，未用,0.8/,万,激素替代疗法,2-4,倍,导管相关性,44,VTE,风险评估,DVT well,s,评分,PE well,s,评分,日内瓦评分,VTE,风险评分（,Caprini,模型）,45,Well,s Criteria(DVT),Well,s Criteria(DVT),Active cancer(tx within 6 mos or palliative care)(1),Calf swelling(3 cm difference,10 cm below tib tub)(1),Collateral superficial veins (1),Paralysis,paresis,or recent immobilization LE (1),Pitting edema confined to involved leg (1),Bedridden within 3 days or surgery w/anesth 3cm,erythema,pitting edema affected leg only),+3,PE Is#1 Diagnosis,or Equally Likely,+3,Heart Rate 100,+1.5,Immobilization at least 3 days,or Surgery in the Previous 4 weeks,+1.5,Previous,objectively diagnosed PE or DVT?,+1.5,Hemoptysis,+1,Malignancy w/Rx within 6 mo,or palliative?,+1,2:Low 2 to 6:Moderate 6:High,Adapted with permission from Wells PS,Anderson DR,Rodger M,Ginsberg JS,Kearon C,Gent M,et al.Derivation of a simple,clinical model to categorize patients probability of pulmonary embolism:increasing the models utility with the SimpliRED d-dimer.,Thromb Haemost 2000;83:416-20.Am J Med 2002;113:270,Revised Geneva score,48,Torbicki A.European Heart Journal(2008)29,2276,2315,Caprini Risk Assessment Model,49,Bahl V,Ann Surg 2009.EpubSeptember 22,Caprini Risk Assessment Model,风险因素总分,风险等级,DVT,发生率,推荐预防方案,0-1,低危,10%,早期活动,2,中危,10-20%,药物预防或物理预防,3-4,高危,20-40%,药物预防和或物理预防,5,极高危,DVT,发生率,40-80%,，死亡率,1-5%,药物预防和物理预防,50,51,K Deatrick,Phlebology 2010;25:296,311,E-Alerts Can Increase Prophylaxis,2506 hospitalized patients,VTE risk score 4,Randomized to intervention or control,Intervention,Treatment Received,Mechanical,%,Pharmacologic,%,E-Alert,10,23.6,Control,1.5,13,P,-value,0.001,0.001,Kucher N,et al.N Engl J Med.2005;352:969-977.,major risk factors of cancer,prior VTE,and hypercoagulability were assigned a score of 3;,the intermediate risk factor of major surgery was assigned a score of 2;,and the minor risk factors of advanced age,obesity,bed rest,and the use of hormone-replacement therapy or oral contraceptives were assigned a score of 1.,53,Kucher N,et al.N Engl J Med.2005;352:969-977.,Intervention,Control,Time,(,days,),0,30,60,90,%Freedom from DVT/,PE,90,92,94,96,98,100,E-Alerts Decrease VTE,Kucher N,et al.N Engl J Med.2005;352:969-977.,Intervention,Control,N,umber,at risk,1255,977,900,1251,976,893,839,853,41%,P=0.001,Effectiveness can wane over time,Lecumberri R,et al.Thromb Haemost.2008;100:699-704.,*P 0.05,*,56,祈予指正！,后面内容直接删除就行,资料可以编辑修改使用,资料可以编辑修改使用,主要经营：网络软件设计、图文设计制作、发布广告等,公司秉着以优质的服务对待每一位客户，做到让客户满意！,致力于数据挖掘，合同简历、论文写作、,PPT,设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求,感谢您的观看和下载,The user can demonstrate on a projector or computer,or print the presentation and make it into a film to be used in a wider field,