肿瘤相关性静脉血栓栓塞症诊断与治疗.ppt

住院卧床抗凝预防推荐 对于无抗凝禁忌的所有肿瘤住院患者（卧床≥4天），应进行预防性抗凝。预防性抗凝应贯穿整个住院期间 成年肿瘤住院患者在开始血栓预防治疗之前，应确认是否有抗凝禁忌 诊断评估方法 * Everyone I’m sure is familiar with Virchow’s triad. It was first described by this German pathologist. If we think of risk factors, we should think of them as the embodiment of the triad: hypercoagulability, stasis, and vessel injury. So, essentially, under normal conditions, microthrombi are continually formed and lysed with the venous circulatory system. When any one of the “risk states” exists, potential microthrombi may escape the normal fibrinolytic system and grow and propagate. Pulmonary Emboli occurs when fragments of thrombus break loose and are carried through the right side of the heart into the pulmonary arterial tree. 1865年 * 肿瘤细胞与凝血系统互相影响。例如肿瘤细胞产生的促凝因子促进凝血，肿瘤的生长导致血流的淤滞等。同时，凝血系统的激活促进肿瘤细胞生长。所以这些影响是相互的，多方面的。 * NCCN ASCO * NCCN-2010 ASCO-2007 维生素K拮抗剂（VKA） 国际标准化比值(INR)的变化 * 健康成年人，INR值大约1.0。有静脉血栓的患者的INR值一般应保持在2.0～2.5之间；有心房纤维性颤动的患者的INR值一般应保持在2.0～3.0之间。然而，理想的INR值一定要为每一个病人制定个性化指标。当INR值高于4.0时，提示血液凝固需要很长时间，这可能引起无法控制的出血，甚至死亡。而INR低于2.0不能提供有效的抗凝。 * * Patients with metastasized or locally advanced solid tumors were randomly assigned to receive a 6-week course of subcutaneous nadroparin or placebo. The primary efficacy analysis was based on time from random assignment to death. The primary safety outcome was major bleeding. In the a priori specified subgroup of patients with a life expectancy of 6 months or more at enrollment, the hazard ratio was 0.64 (95% CI, 0.45 to 0.90) with a median survival of 15.4 and 9.4 months, respectively. For patients with a shorter life expectancy, the hazard ratio was 0.88 (95% CI, 0.62 to 1.25） * Breast cancer was more frequent in the Fraxiparine? group, whereas colorectal and cervical cancers were seen more often in the placebo group. A small proportion of patients did not have metastatic disease. The types of locally advanced disease in this group included hepatocellular, oesophageal, and pancreatic cancer. * In t