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不同时间段抗凝治疗中脑出血预测——来自RIETE登记的研究发现

Predicting intracranial bleeding during anticoagulation for venous thromboembolism within different time frames: Findings from the RIETE registry

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影响因子:3.4
分区:医学3区 / 血液学2区 外周血管病3区
发表日期:2024 Nov
作者: Ana Maestre, Mar Martín Del Pozo, Farès Moustafa, Romain Chopard, José Antonio Nieto, María Ángeles Fidalgo Fernández, Patricia López Miguel, Peter Verhamme, Maurizio M Ciammaichella, Manuel Monreal,
DOI: 10.1016/j.thromres.2024.109153

摘要

抗凝治疗VTE(静脉血栓栓塞)期间发生脑出血的风险很高,并且在治疗初期之后仍持续存在。我们旨在通过阶段特异性预后评分,优化风险评估。我们从2009年3月至2023年10月的RIETE登记中筛选出77,786例VTE患者数据,开发了两种脑出血的预后评分。采用多变量Cox回归分析不同变量对早期(≤90天)和晚期(>90天)阶段的影响,并与现有评分(修订版ACCP、RIETE、VTE-BLEED和CHAP)进行对比验证。脑出血发生在411例患者中(0.53%),其中早期发生208例,晚期发生203例。30天内的死亡率分别为45%和35%。两阶段的共同显著预测因素包括基线异常精神状态、脑癌、近期脑出血和癫痫。早期出血特有的预测因素包括体重、非脑癌、高血压、痴呆、血小板减少、肾功能不全及溶栓治疗。年龄较大、最初伴随肺栓塞、既往中风、抑郁症、使用直接口服抗凝剂及糖皮质激素的使用,均为晚期出血的预测因素。两个预后评分的c-统计量均为0.68,优于现有模型。本研究提出了两个时间段的脑出血预后评分,能根据不同治疗阶段的特定风险因素进行区分,超越传统模型,为临床决策提供了先进工具。这些评分具有优化抗凝管理和降低出血相关死亡率的重要潜力。

Abstract

The risk of intracranial bleeding during anticoagulation for venous thromboembolism (VTE) is substantial and persists beyond the initial treatment phase. We aimed to refine risk-assessment through phase-specific prognostic scores.We identified data from 77,786 VTE patients in the RIETE registry from March 2009 to October 2023 to develop two prognostic scores for intracranial bleeding. Multivariable Cox regression was used to analyze distinct variables for the early (≤90 days) and late (>90 days) phases, with comparative validation against existing scores (modified ACCP, RIETE, VTE-BLEED, and CHAP).Intracranial bleeding occurred in 411 patients (0.53 %), with 208 cases in the early phase and 203 in the late phase. The 30-day mortality was 45 % and 35 %, respectively. Shared significant predictors for both phases include baseline abnormal mental status, brain cancer, recent intracranial bleeding, and epilepsy. Unique to early-phase bleeding were body weight, non-brain cancer, hypertension, dementia, thrombocytopenia, renal insufficiency, and thrombolytic therapy. Advanced age, pulmonary embolism initially, prior stroke, depression, treatment with direct oral anticoagulants, and use of corticosteroids predicted late-phase bleeding. Both prognostic scores showed a c-statistic of 0.68, outperforming existing scores.The study introduces two temporal prognostic scores for intracranial bleeding during anticoagulation for VTE. By discerning specific risk factors pertinent to each treatment phase, these scores outperform traditional models, offering an advanced tool for clinical decision-making. They hold significant potential for optimizing anticoagulation management and reducing bleeding-related mortality.