中国静脉血栓栓塞症研究现状

1、中国静脉血栓栓塞症研究现状赵永强北京协和医院血液科静脉血栓栓塞症的流行病学(venous thromboembolism, VTE)总人群中VTE的年诊断率西方国家：0.52 / 1000。中国大陆：无大规模调查的流行病学数据。中国香港：0.167 / 1000是否中国人VTE发生率确实低于高加索人。malignanciesstrokeChina(Zhang, 2001)2.8%(n=106)6.7%(n=120)Sweden(Nordstrom, 1994)39%(n=383)UK(Johnson, 1999)52%(n=258)Canada(Turpie, 1992)28%(n=25)内科

2、疾病中VTE的发生率nHip & knee replacementChina (Yang, 2000)6248.4% (Li, 2002)1635.4%France40013.5%USA (Davidson, 1996)47470%外科疾病中VTE的发生率近10年国内杂志发表的有关VTE的文章数目中国人VTE“发生率低”需考虑的影响因素 医师对VTE认知度？诊断技术？近10年北京协和医院新诊断的VTE病例数中国人VTE“发生率低”需考虑的影响因素 医师对VTE认知度？诊断技术？Duplex ultrasoundContrast venographyVentilation-perfusion s

3、canCTV/HCTPA亚临床型VTE比西方人多致死性VTE比西方人少纤溶活性比西方人强？食物和其他环境因素？中国人VTE“发生率低” 的人种和饮食环境因素VTE的遗传性危险因素在高加索人群中，最常见的遗传性危险因素为：两种基因突变: 因子V Leiden突变 凝血酶原G20210A突变 VTE患者中的检出率50%。三种抗凝蛋白缺乏： 蛋白C、蛋白S和抗凝血酶缺乏 VTE患者中的检出率1015%。DVT患者中FV Leiden突变*高加索人群中因子V Leiden突变的检出率37%.。APC-RFV LeidenDVTcontrolDVTcontrolChinese Han nationali

4、ty Mainland (Chu, 1996)5/31(16%)5/106(4.7%)0/310/141 (Bai, 2000)4/87(4.6%)0/600/870/60 Taiwan (Shen, 1997)0/850/85Chinese Kazak nationality (Xing, 2001)3/85(3.5%)Japan (Zama, 1996)3/33(9%)0/630/290/53Europe (Koster, 1993)1 (den Heijer, 1996)264/301(21%) 114/301(5%) 147/269(17.5) 27/269(2.6%) 2*DVT患者

5、中凝血酶原基因G20210A突变*高加索人群中凝血酶原G20210A突变约占 2%。Prothrombin gene G20210A mutationDVTcontrolChina (Bai, 2000)0/980/100 (He, 2002)0/1030/106UK (Cumming, 1997)12/219 (5.5%)2/164 (1.2%)Holland (Poort, 1996)18%1%*DVT患者中抗凝蛋白缺乏nDeficient proteinsATPCPSTotalChina Mainland (Bai, 2000)875(5.7%)8(9.2%)13(14.9%)26(29

6、.9%) Taiwan (Shen, 1997)853(3.5%)16(18.8%)28(32.9%)47(55.3%) Hong kong (Liu, 1994)525(9.6%)9(17.3%)10(19.2%)24(46.1%)Japan (Suehisa, 20011132(1.8%)9(8.0%)20(17.7%)31(27.4%)Europe (den Heijer, 1996) 26910(3.7%)15(5.6%)7(2.6%)32(11.9%)DVT患者中高同型半胱氨酸血症Plasma homocysteine (mol/L)PDVTControlChina (Qiu, 20

7、03)13.08.7(n=69)10.14.3(n=111)0.05 (Gao, 2003)14.511.0(n=33)10.74.6(n=33)0.05Holland (den Heijer, 1996)12.9(4.8-60.2)(n=269)12.3(6.4-37.5) (n=269)高同型半胱氨酸血症定义为高于对照组90* 或 95#百分位水平。DVT患者中高同型半胱氨酸血症hyperhomocysteinemiaOddsRatioDVTControlChina (Qiu, 2003)*15/69 (21.7%)11/111 (9.9%)2.5 (Gao, 2003)*21/33 (6

8、3.6%)4/33 (12.1%)9.5Holland (den Heijer, 1996)#28/269 (10.4%)13/269 (4.8%)2.5VTE遗传性危险因素小结抗凝蛋白缺乏其他/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Wu1994DVTYang1996DVTXu2000DVTPan1999PTEAo2003PTEGuo2003PTEWang2004VTETotal (%)n231176103621491062181045*phlebitis / Varicosis441513255601120

9、0 (19.1%)surgery26452411111846181 (17.3%)Trama/fracture21322010252341172 (16.5%)Prolonged bed rest /Immobilazation35311354 106 (10.1%)malignancies751411101023 80 (7.7%)Hypertension/Atherosclerosis2320114 58 (6.2%)Chronic heart diseases1341811 46 (4.9%)Pregnancy/delivery138121 25 (2.4%)CTD8124 14 (1.

10、5%)NS1661 8 (0.9%)others57294410664156 (14.9%)unknown2818127212862176 (16.8%)*One patient may have more than one factors. VTE获得性危险因素分析Wu1994DVTYang1996DVTXu2000DVTPan1999PTEAo2003PTEGuo2003PTEWang2004VTETotal (%)n231176103621491062181045*phlebitis / Varicosis4415132556011200 (19.1%)surgery2645241111

11、1846181 (17.3%)Trama/fracture21322010252341172 (16.5%)Prolonged bed rest /Immobilazation35311354 106 (10.1%)malignancies751411101023 80 (7.7%)Hypertension/Atherosclerosis2320114 58 (6.2%)Chronic heart diseases1341811 46 (4.9%)Pregnancy/delivery138121 25 (2.4%)CTD8124 14 (1.5%)NS1661 8 (0.9%)others57

12、294410664156 (14.9%)unknown2818127212862176 (16.8%)*One patient may have more than one factors. VTE获得性危险因素分析根据两项全国范围的调查，外周血管病患者中有静脉炎或静脉曲张者占1219.6%，明显高于西方国家，原因不明。Wu1994DVTYang1996DVTXu2000DVTPan1999PTEAo2003PTEGuo2003PTEWang2004VTETotal (%)n231176103621491062181045*phlebitis / Varicosis44151325560112

13、00 (19.1%)surgery26452411111846181 (17.3%)Trama/fracture21322010252341172 (16.5%)Prolonged bed rest /Immobilazation35311354 106 (10.1%)malignancies751411101023 80 (7.7%)Hypertension/Atherosclerosis2320114 58 (6.2%)Chronic heart diseases1341811 46 (4.9%)Pregnancy/delivery138121 25 (2.4%)CTD8124 14 (1

14、.5%)NS1661 8 (0.9%)others57294410664156 (14.9%)unknown2818127212862176 (16.8%)*One patient may have more than one factors. 2 risk factors: 58% 3 risk factors: 31%4 risk factors: 14%VTE获得性危险因素分析VTE患者的性别分布汇总几项大宗国内研究，1741名VTE患者的性别分布为： 男 : 女 = 1091 : 650 (1.68 : 1)国外同类研究：高加索人群和其他亚洲人群中无明显性别差异。 VTE患者的年龄分布

15、汇总几项大宗国内研究，1741名VTE患者的性别分布为： 1390（中位年龄 49.7 )N=576 Data from: Xu, 2000 Ao, 2003 Guo, 2003 Wang, 2004The first episodes of VTE were most common at age 4060, that was about 10 years younger than that of Caucasians.90% of DVT involved lower limbes Frequencies of PTE in the patients presented with DVT:

16、11.144.7%Frequencies of DVT in the patients presented with PTE: 4266%汇总几项大宗国内研究，计1741名VTE患者2001 Guideline on diagnosis and treatment of PTE The Society of Respiratory diseasesChinese Medical AssociationClinical suspicion of PTEVentilation and perfusion scanCompression ultrasound venographyD-Dimer Co

17、nfirmation of PTEHCTPA or Contrast PA if necessaryAnticoagulant therapyFibrinolytic therapy if indicated(+)(-)Exclusion of PTEFellowup if necessary(-)(+)Risk factor screenHCTPA: helical CT pulmonary angiography总的印象汉族人与高加索人相比：VTE的发生率可能较低，但这需经进一步大规模流行病学研究的证实。 抗凝蛋白缺乏，尤其是蛋白S的缺乏，是最常见的遗传性缺陷。发病年龄较轻，需进一步证实。

18、即使确如此，原因尚难解释。AcknowledgmentPeking Union Medical College Bai Chun-mei, et al. Natl Med J china, 1999, 79: 900 Bai Chun-mei, et al. Chin J Intern Med, 2000, 39: 746 Zhang Xiao-fei, et al. Chin J Contr Chron Non-commun Dis, 2001, 9: 206 He Jian-guo, et al. Natl Med J china, 2001, 81: 1490 He Jian-guo, et al. Natl Med J china, 2002, 82: 1730 Qiu Ling, et al. Acta Acad Med Sin, 2003, 25: 706 Gao Ying, et al. J Cardiovasc Pulmon