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ID naloge: 66 Letnik: 1999 Predmet: interna medicina
Vpliv dolgotrajnega antikoagulacijskega zdravljenja na fibrinoliticno aktivnost krvi pri bolnikih z vensko trombozo
Avtor: Maja Jarc, Eva Zemljic
Mentor: prof.dr.Polona Peternel
Somentor: mag.Barbara Salobir - Pajnic
Venska tromboza (VT) pomembno poveca obolevnost in umrljivost bolnikov z omejeno gibljivostjo in malignomi. Ogroža tudi bolnike, pri katerih pride zaradi številnih drugih okolišcin, do zastoja krvi in aktivacije koagulacije. Temeljno zdravljenje VT je antikoagulacijsko; je dolgotrajno in ni brez zapletov. Vpliv antikoagulacijskega zdravljenja na fibrinoliticno aktivnost krvi je slabo proucen.
V raziskavo smo vkljucili 99 zaporednih bolnikov, ki so se med majem in decembrom 1998 zdravili na Interni kliniki - Klinicnem oddelku za žilne bolezni zaradi objektivno potrjene VT. Med njimi je bilo 42 (42%) moških in 57 (58%) žensk. Bolniki so bili stari povprecno 60 (±10 let) let. Starejših od 65 let je bilo 47 (47%) bolnikov. Pri 41 (46%) bolnikih smo VT opredelili kot primarno, pri 48 (54%) pa kot sekundarno. Malignom je bil prisoten pri 20 (20%) bolnikih. 52 (67%) bolnikov je imelo povecan indeks telesne mase (BMI>25 kg/m2). Bolnike smo spremljali klinicno in laboratorijsko med zdravljenjem v bolnici in ambulantno šest mesecev po akutnem dogodku.
Med raziskavo je umrlo 8 (8%) bolnikov: pri 6 bolnikih je bil vzrok smrti napredovan malignom, pri 2 vzrok smrti ni bil znan. Pljucno embolijo (PE) je doživelo 10 (10%) bolnikov v akutnem obdobju. VT se je ponovila pri dveh (2%) bolnikih, PE pri enem (1%) bolniku. Z ultrazvocnim pregledom šest mesecev po odpustu iz bolnice smo ugotovili, da je do rekanalizacije prizadete žile prišlo pri vec kot štirih petinah bolnikov.
Z meritvijo protrombinskega casa, izraženega z INR (International Normalised Ratio), smo ocenjevali urejenost antikoagulacijskega zdravljenja s kumarini. Bolniki starejši od 65 let in bolniki z malignomom so potrebovali manjše odmerke kumarinov kot mlajši bolniki oziroma bolniki brez malignoma. Po odpustu iz bolnice je bila polovica izmerjenih INR v terapevtskem obmocju (INR 2,0-3,0). Bolniki z malignomom so bili v terapevtskem obmocju le cetrtino casa (p<0,05). Vecjo krvavitev med antikoagulacijskim zdravljenjem je utrpela 1 (1%) bolnica z malignomom.
V akutnem obdobju bolezni smo izmerili pomembno višje vrednosti fibrinogena (p<0,001) in D-dimerov (p<0,001). Obe spremenljivki sta po akutnem obdobju padli, vendar so bile vrednosti fibrinogena med ambulantnim spremljanjem bolnikov pomembno višje pri starejših in debelih bolnikih. Pri vseh bolnikih se je po akutnem obdobju cas evglobulinske lize znacilno podaljšal (p<0,03).
Rezultati naše raziskave kažejo, da je urejenost dolgotrajnega antikoagulacijskega zdravljenja VT enaka pri starejših in mlajših bolnikih, slabša pa pri bolnikih z malignomom. Povecanje fibrinogena in D-dimerov v akutnem obdobju VT smo povezovali s trombozo samo. Dolgotrajno antikoagulacijsko zdravljenje je sovpadalo s podaljšanimi casi evglobulinske lize, iz cesar domnevamo, da to zdravljenje vpliva na fibrinoliticno aktivnost krvi
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[Abstract / English version]
The influence of the anticoagulant treatment on the blood fibrinolytic activity in patients with venous thrombosis
Author: Maja Jarc, Eva Zemljic
Mentor: prof.dr.Polona Peternel
Co-mentor: mag.Barbara Salobir - Pajnic
Venous thrombosis (VT) significantly increases the morbidity and mortality in patients with immobilisation and malignancy. It also threatens the patients with numerous clinical conditions related to stasis and hypercoagulation of blood. The basic treatment of the VT is anticoagulant which is long-term and not without complications. The influence of the anticoagulant treatment on the blood fibrinolytic activity has so far not been investigated extensively.
From May 1998 to December 1998, 99 consecutive patients were diagnosed as having acute VT in our hospital. Among them were 42 (42%) men and 57 (58%) women. The mean age of patients was 60 (±10 years) years. Older than 65 were 47 (47%) patients and 52 (53%) of them were younger than 65. In 41 (46%) patients the VT has been stated as idiopathic and in 48 (54%) as secondary, respectively. Cancer was present in 20 (20%) patients. Increased body mass index (BMI>25 kg/m2) was present in 52 (67%) patients. The patients were observed during their hospitalisation and the clinical follow-up six months after the acute occurrence of VT.
During the study 8 (8%) patients died, in 6 patients the advanced malignancy was the death cause and in 2 patients the death cause was not known. Ten (10%) patients had clinically apparent pulmonary embolism (PE). The VT recurred in 2 (2%) patients and PE in 1 (1%). Six months after the release from hospital the Doppler sonography showed a recanalisation of the affected vein in four fifths of the patients.
The balance of the coumarin anticoagulant treatment was measured by the prothrombin time. Results of this test were expressed in INR (International Normalised Ratio). Lower coumarin doses were needed in patients older than 65 and in those with cancer. After the release from hospital, half of the measured INR was within the therapeutic range (INR 2.0 - 3.0). The patients with cancer were within the therapeutic range for the quarter of the time (p<0.05) only. One (1%) patient with cancer suffered major bleeding during the anticoagulant treatment.
During the acute phase of the disease, an increase in concentration of the fibrinogen (p<0.001) and the D-dimer (p<0.001) was noted. Both variables decreased in the later course of the disease, but older patients had a significantly higher concentration of the fibrinogen than the younger (p<0.01). Euglobuline clot lysis time was significantly prolonged after the acute phase (p<0.03).
The obtained results show that the quality of the long-term anticoagulant treatment of VT is equal in old and young patients. Compared to the patients with no cancer, the patients suffering from cancer are less balanced. The increase of the fibrinogen and the D-dimer during the acute phase of the VT can be related to the VT only. The long-term coumarin anticoagulant treatment coincides with the prolongation of euglobuline clot lysis time. We presume that the long-term anticoagulant treatment influence the blood fibrinolytic activity.
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