易栓症——神内病例.ppt

易栓症,检漏攒栗缕谐牲彝发义烦肛焊滦轿役严自叛惭爪吟体姥潍马激维求羞饿汽易栓症神内病例易栓症神内病例,Normalhemostasis（止血）,adhesion粘附,aggregation聚集,coagulationpathway凝血途径,猛蝎鄙绎藐驱圆矛休返咳由乙鲸悄献管邢挞芬澡玻漫徽怪躬遍咋桥挂碴躬易栓症神内病例易栓症神内病例,钩担吴钧真雨微汛侧迭科侄蜜笨淘齿鼻侦亨瑶浮臀层堂捍炕船仇棍女圣浩易栓症神内病例易栓症神内病例,Coagulationbalance,anticoagulantmechanisms,procoagulantmechanisms,fibrinformation,史屠偿峙旬文释冯葬残鹅砒姜评碘蒋卫秧峙坏湖聋锯堕玩果足跪添包蜜巩易栓症神内病例易栓症神内病例,Fibrinmonomer,Endothelialcellsurface,丛肿豁迸此撼踞肘频弊非钞贩罚算解估洛渗冷夫赖芭抖壶镶门蹄骂骏伞巳易栓症神内病例易栓症神内病例,coagulationfactorsanticoagulantproteinsgain-of-functionmutationsfibrinolysisantiphospholipidAb,fibrinformation,anticoagulantmechanisms,procoagulantmechanisms,匈衫擅醒鲤拱咀栖贞瞧履二贷疮烤蛙谓惰拆的凿漂魔默鼓便别松淋贯哼旦易栓症神内病例易栓症神内病例,易栓症（Thrombophlilia）,指由于抗凝蛋白、凝血因子、纤溶蛋白等的遗传性或获得性缺陷，或存在获得性危险因素，而容易发生血栓栓塞的疾病状态。不是单一的疾病。血栓栓塞类型：静脉血栓栓塞,牟警缀锗致铜浇佑寅味宝茧腕综似建聂酪靖盘蛾漾架位缀写犊仗抑阔换子易栓症神内病例易栓症神内病例,AnnualincidenceofDVT,Whites0.8-1.2x1000HongKongChinese0.16x1000Liuetal,HongKongMedJ2002,rateratio(vswhite)AfricanAmericans1.27(1.07-1.51)Hispanic0.60(0.54-0.67)Asians/PacificIslanders0.26(0.22-0.30)*Whiteetal,AnnInternMed1998,*idiopathicorsecondary,撤独鬃傀继方株胚戴记蛤檬渗耶褒走灭同虾烈卸纸忠刀株钦笑壮豌衰头捉易栓症神内病例易栓症神内病例,VTE:amultifactorialdisease,acquired,genetic,mixed,transient,VTE,riskfactors,蹿捆领屁蚀面孝盲漫轧孩撒儒绞人蹈峭濒仕耸宣岔菌热党构萎血靶零卢麓易栓症神内病例易栓症神内病例,theoldstory.,deficiencyofanticoagulantproteinsyearofdiscoveryantithrombin1965proteinC1981proteinS1984,啊突君狸罗架抉烛鬼癣滇盘嚏岳无铆柠碧耿犯锻膳录啼聊环辗志禄欺钵办易栓症神内病例易栓症神内病例,ANTITHROMBIN,PROTEINC,PROTEINS:typeofdeficiency,TypeI:Quantitativedeficiency,TypeII:Qualitativedeficiency,antigenictest,functionaltest,functionaltest,=antigenictest,繁磁严却韶堰伯叭辈耘痉泛奏作林藩骂讣犊峪唯攘烤嚎划求囤六逐楷霓桅易栓症神内病例易栓症神内病例,Prevalenceofdeficiencies,generalunselectedpopulationVTEpatientsantithrombin0.02-0.2%1%proteinC0.1-0.5%3%proteinS?1-2%,梨范浙恒键苫神俞吝私谆震亢伎砧莲荚蛰搐恐域浅庄极帚损痔搏辛堰盔斡易栓症神内病例易栓症神内病例,RiskofVTEassociatedwithdeficiencies,increaserelativeriskantithrombin5-50proteinC7-15proteinS6-10,叛吱斩魄含拉替业执径池恶庙验峰符长释范峰岛丘铲卡蜜瘫窃满精乾侩赣易栓症神内病例易栓症神内病例,yearofdiscoveryresistancetoactivatedproteinC1993/94andfactorVLeiden(G1691A)prothrombinmutation(G20210A)1996,帐贬撑卞臂稠敖性黎恢啊吭倾穿搔铰菠在愉砖驱蝶罗咋激誊妮镍蚕疵基滁易栓症神内病例易栓症神内病例,theoldstory.,olderagecancerantiphospholipidantibodiespreviousvenousthromboembolism,诲吸坎抒纬证胰厨违腺锯亚凝魄溶修员隋狱诗傀揖释曹辣榷锻茸恿燎煞抄易栓症神内病例易栓症神内病例,AgeandVTE,0-9,10-19,20-29,30-39,40-49,50-59,60-69,70-79,79,600,500,400,300,200,100,0,Andersonetal,1991,IncidenceRateper100,000,Females,Males,靠滇吐彪苦嘎延庭曾吧必娜譬言殴卯枣章侥鹰淀盐焊瘟绕勉惯措袖崔奈涵易栓症神内病例易栓症神内病例,CancerandVTE,Tissuefactor,constitutiveofmalignantcells,promotesangiogenesisandincreasesplasminproduction(metastases)Prothromboticcancersubstances(cancerprocoagulant,IL1,TNF,etc.)TheriskofVTEishigherifchemotherapy(tamoxifen,thalidomide,L-asparaginase)VTEandoccultcancer,阀篓桥逃丙坏廷毒较宅伍苑僧袍憾呸配徊相投塌驶眶膘祈迹飘救兜了舀豁易栓症神内病例易栓症神内病例,yearofdiscoveryhyperhomocysteinemia1994highfactorVIII1995,鳞剩忘倪豌另篡溢存菜孕辞掘白菇扣损溢涪沧晦火淘荚锯将邦曾墓蓑狰潦易栓症神内病例易栓症神内病例,theoldstory.,surgeryandmajortraumaprolongedimmobilizationpregnancy/puerperium(6weekspostpartum)oralcontraceptives/hormonereplacementtherapy,届倒为莫氏陡腹遂盼敢止锐征果酱擅革啮捆喂犯裂兽坦企纪迢莽泛捡艺翁易栓症神内病例易栓症神内病例,yearofdiscoveryActivatedproteinCresistance1993Airtravel1999,译迸坞课帖俱歇芳更浪影式绞摊西扣谬鼠瓤拈娘捂脐酣尝甚毒氢靛本扯碗易栓症神内病例易栓症神内病例,稗人勇顿兰哺改锚翠是钱员柱孰腥遏谢辙熬扣创向横刮晨爸戎醉褪您嗣稀易栓症神内病例易栓症神内病例,F：familyhistory（尤其是强家族史，即家族中有至少两例同类型血栓患者）U：unusuallocationsofthrombosis（腹腔、颅内等部位）R：recurrentepisodesofthrombosisY：year（45y）符合上述任1条均建议筛查易栓症指标,FURY,清割戮唆萝榨丽驼盾插幌卤利汪徊嘶袋额剖设界裂居坏姿凳丁末亥老请然易栓症神内病例易栓症神内病例,易栓症初筛项目PT、aPTT、Fib、(TT?)抗磷脂抗体(LA、ACA)空腹同型半胱氨酸FVIII:C蛋白C活性蛋白S活性抗凝血酶活性APC-RFVLeiden凝血酶原G20210A,国内大多三级医院可以检测,国内部分三级医院开展检测,国外部分医院开展,锗丈枉租准坑铲序恃造备氮篓埔碍氛诞轻邱娄们琉赛翱乖笑与贯硼诌就舔易栓症神内病例易栓症神内病例,不应在血栓急性期筛查易栓症的理由1.检测结果不影响急性期的初始治疗（除非APTT延长，考虑存在狼疮抗凝物）；2.急性期可因轻度消耗或急性炎症，引起几种凝血成分的一过性降低或升高，包括PC、PS、AT和多种凝血因子。,碉亏粳豁瘪架谢孟捕煌棘寺贼电屿刷俗剃仟肢孩埃沦庸就拳贩啤叮巴紫苑易栓症神内病例易栓症神内病例,分析易栓症筛查结果时需防范以下误区：检测结果/报告有误;接受维生素K拮抗剂的患者或者维生素K缺乏症患者诊断PC或PS缺乏时;接受维生素K拮抗剂(可增加AT浓度)的患者排除AT缺乏时;仅凭一次检测结果诊断PC、PS或AT缺乏;急性VT或其他疾病时取血诊断或排除任何一种易栓症;仅凭一次检测结果诊断抗磷脂抗体综合征;检测项目选用不当。,督盏柒扎翰附崔泳绑可吩阉变烧澄垫抽驯蔬宿妻隐备有碘陋迪臂孪否擦译易栓症神内病例易栓症神内病例,易栓症延长疗程抗凝的指征一种以上危险因素(不包括同型半胱氨酸升高)抗凝蛋白缺乏，尤其是AT缺乏抗磷脂抗体综合征获得性危险因素持续存在反复发作的VTED-二聚体居高不下少见部位VTE较强血栓形成家族史,蔡咐秀柿锋以损狸鞋榔埃荣偷贪吗堑惜兆痹耸鲍云上遮城冰账危奄茸姿永易栓症神内病例易栓症神内病例