medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2017-7-48-55medsovet-1769Research ArticleТРОМБОЗЫ И ТРОМБОЭМБОЛИИTHROMBOSIS AND THROMBOEMBOLISMКАКИМ ОБРАЗОМ НОВЫЕ ПОДХОДЫ К ТЕРАПИИ ТРОМБОЭМБОЛИИ ЛЕГОЧНОЙ АРТЕРИИ ВЛИЯЮТ НА ИСХОДЫ ЗАБОЛЕВАНИЯ?HOW NEW APPROACHES TO THE TREATMENT OF PULMONARY EMBOLISM AFFECT THE OUTCOME OF THE DISEASE?ГиляровМ. Ю.GilyarovM. Y.

д.м.н., профессор,

Москва

MD, Prof.,

КонстантиноваЕ. В.KonstantinovaE. V.

д.м.н.,

Москва

MD

Первый Московский государственный медицинский университет им. И.М. Сеченова; Городская клиническая больница №1 им. Н.И. Пирогова Департамента здравоохранения г. МосквыРоссияFirst Moscow State Medical University named after I.M. Sechenov; City Clinical Hospital №1 named after N.I. Pirogov, Moscow Healthcare DepartmentRussian FederationРоссийский национальный исследовательский медицинский университет им. Н.И. Пирогова; Городская клиническая больница №1 им. Н.И. Пирогова Департамента здравоохранения г. МосквыРоссияMoscow Russian National Medical Research University named after N.I. Pirogov; City Clinical Hospital №1 named after N.I. Pirogov, Moscow Healthcare DepartmentRussian Federation201730122017074855Copyright © Гиляров М.Ю., Константинова Е.В., 20172017Гиляров М.Ю., Константинова Е.В.Gilyarov M.Y., Konstantinova E.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/1769

Тромбоэмболия легочной артерии (ТЭЛА) является основной потенциально обратимой причиной госпитальной смертности. В помощь практическому врачу ведущими экспертами разных стран разрабатываются и обновляются рекомендации, в которых анализируются и обобщаются подходы к терапии ТЭЛА. Среди причин положительной динамики исходов у пациентов с ТЭЛА (согласно регистру RIETE) за последние годы рассматриваются усовершенствование диагностических подходов, а также техническое усовершенствование томографических сканеров. Еще одной причиной улучшения исходов пролеченных больных с тромбозом глубоких вен и ТЭЛА стала оптимизация антикоагулянтной терапии. Появление «новых» оральных антикоагулянтов (НОАК: ривароксабан, дабигатран, апиксабан) ознаменовало начало качественно нового подхода к терапии ТЭЛА за счет удобства лечения без необходимости регулярного контроля параметров сверты- вания крови. Помимо появления новых удобных и эффективных препаратов, поменялась и тактика диагностики и терапии пациентов, что нашло отражение в обновленных рекомендациях по ведению пациентов с венозными тромбоэмболическими осложнениями (ESC 2014, ACCP 2016).

Pulmonary embolism (PE) is the key potentially reversible cause of in-hospital mortality. To help the practitioner, leading experts in different countries are developing and updating guidelines which analyze and generalize approaches to the treatment of PE. Recently, among the factors leading to positive dynamics in outcomes of patients with PE (according to the RIETE registry),the researchers have considered improvement of diagnostic techniques as well as technical improvements in tomographic scanners. Another reason for improved outcomes of treated patients with deep vein thrombosis and pulmonary embolism is optimization of anticoagulation therapy. The emergence of “new” oral anticoagulants (NOAC: rivaroxaban, dabigatran, apixaban) marked the beginning of a qualitatively new approach to the treatment of PE characterized by convenience of treatment without the need for regular monitoring of blood coagulation parameters. In addition to the emergence of new convenient and effective drugs, the approach to diagnosis and treatment of patients also changed, as reflected in the updated guidelines for the management of patients with venous thromboembolic complications (ESC 2014, ACCP 2016).

ТЭЛАантикоагулянтытромбоэмболияривароксабандабигатранапиксабанPEanticoagulantsthromboembolismrivaroxabandabigatranapixabanReferencesKonstantinides SV, Torbicki A, Agnelli G et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). European Heart Journal, 2014, 35: 3033-3080.Konstantinides SV, Torbicki A, Agnelli G et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). European Heart Journal, 2014, 35: 3033-3080.Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol, 2008, 28(3): 370–372.Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol, 2008, 28(3): 370–372.Cohen AT, Agnelli G, Anderson FA et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost, 2007, 98(4): 756–764.Cohen AT, Agnelli G, Anderson FA et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost, 2007, 98(4): 756–764.Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med, 2011, 171: 831–7.Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med, 2011, 171: 831–7.Carrier M, Righini M, Wells PS, et al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implicationsA systematic review and meta-analysis of the management outcome studies. J Thromb Haemost, 2010, 8: 1716–22.Carrier M, Righini M, Wells PS, et al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implicationsA systematic review and meta-analysis of the management outcome studies. J Thromb Haemost, 2010, 8: 1716–22.Heit JA, Silverstein MD, Mohr DN, et al. Predictors of survival after deep vein thrombosis and pulmonary embolism: a populationbased, cohort study. Arch Intern Med, 1999, 159: 445–453.Heit JA, Silverstein MD, Mohr DN, et al. Predictors of survival after deep vein thrombosis and pulmonary embolism: a populationbased, cohort study. Arch Intern Med, 1999, 159: 445–453.Becattini C, Agnelli G, Pesavento R, et al. Incidence of chronic thromboembolic pulmonary hypertension after a first episode of pulmonary embolism. Chest, 2006, 130(1): 172–175.Becattini C, Agnelli G, Pesavento R, et al. Incidence of chronic thromboembolic pulmonary hypertension after a first episode of pulmonary embolism. Chest, 2006, 130(1): 172–175.Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med, 2004, 350(22): 2257–2264.Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med, 2004, 350(22): 2257–2264.Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet, 2010, 376(9757): 2032–2039.Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet, 2010, 376(9757): 2032–2039.Zhu T, Martinez I, Emmerich J. Venous thromboembolism: risk factors for recurrence. Arterio scler Thromb Vasc Biol, 2009, 29(3): 298–310.Zhu T, Martinez I, Emmerich J. Venous thromboembolism: risk factors for recurrence. Arterio scler Thromb Vasc Biol, 2009, 29(3): 298–310.Heit JA. Predicting the risk of venous thromboembolism recurrence. Am J Hematol, 2012, 87(Suppl 1): 63–67.Heit JA. Predicting the risk of venous thromboembolism recurrence. Am J Hematol, 2012, 87(Suppl 1): 63–67.Beckman MG, Hooper WC, Critchley SE, Ortel TL: Venous thromboembolism: a public health concern. Am J Prev Med, 2010, 38: 495–501.Beckman MG, Hooper WC, Critchley SE, Ortel TL: Venous thromboembolism: a public health concern. Am J Prev Med, 2010, 38: 495–501.Deitelzweig SB, Johnson BH, Lin J, Schulman KL: Prevalence of clinical venous thromboembolism in the USA: Current trends and future projections. Am J Hematol, 2011, 86: 217–220.Deitelzweig SB, Johnson BH, Lin J, Schulman KL: Prevalence of clinical venous thromboembolism in the USA: Current trends and future projections. Am J Hematol, 2011, 86: 217–220.Европейские рекомендации по диагностике и ведению пациентов с острой эмболией системы легочной артерии 2014 г. Сайт Российского кардиологического общества www.scardio.ru/rekomendacii/rekomendacii_esc.Европейские рекомендации по диагностике и ведению пациентов с острой эмболией системы легочной артерии 2014 г. Сайт Российского кардиологического общества www.scardio.ru/rekomendacii/rekomendacii_esc.Beyer-Westendorf J et al. Venous thromboembolism prevention and treatment: expanding the rivaroxaban knowledge base with real-life data. European Heart Journal Supplements, 2015, 17(Supplement D): D32–D41.Beyer-Westendorf J et al. Venous thromboembolism prevention and treatment: expanding the rivaroxaban knowledge base with real-life data. European Heart Journal Supplements, 2015, 17(Supplement D): D32–D41.Schiro TA, Sakowski J, Romanelli RJ, et al. Improving adherence to best-practice guidelines for venous thromboembolism risk assessment and prevention. Am J Health Syst Pharm, 2011, 68: 2184–2189.Schiro TA, Sakowski J, Romanelli RJ, et al. Improving adherence to best-practice guidelines for venous thromboembolism risk assessment and prevention. Am J Health Syst Pharm, 2011, 68: 2184–2189.Сулимов В.А., Беленцов С.М., Головина Н.И. и др. Распространенность и профилактика тромбоэмболий в клинической практике: российские результаты международного регистра ENDORSE. Клиническая Фармакология и Терапия, 2008, 17(3): 32-40.Сулимов В.А., Беленцов С.М., Головина Н.И. и др. Распространенность и профилактика тромбоэмболий в клинической практике: российские результаты международного регистра ENDORSE. Клиническая Фармакология и Терапия, 2008, 17(3): 32-40.Jiménez D, de Miguel-Díez J, Guijarro R et al. Trends in the management and outcomes of acute pulmonary embolism analysis from the RIETE registry. J Am Coll Cardiol, 2016, 67: 162–70.Jiménez D, de Miguel-Díez J, Guijarro R et al. Trends in the management and outcomes of acute pulmonary embolism analysis from the RIETE registry. J Am Coll Cardiol, 2016, 67: 162–70.Konstantinides SV. Trends in Pulmonary Embolism Outcomes. Are We Really Making Progress? Journal of the American College of Cardiology, 2016, 67(2).Konstantinides SV. Trends in Pulmonary Embolism Outcomes. Are We Really Making Progress? Journal of the American College of Cardiology, 2016, 67(2).Holbrook A, Schulman S, Witt DM et al. Evidence-Based Management of Anticoagulant Therapy. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2012, 141(Suppl): e152S–e184S.Holbrook A, Schulman S, Witt DM et al. Evidence-Based Management of Anticoagulant Therapy. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2012, 141(Suppl): e152S–e184S.Fang MC, Fan D, Witt DM et al. The Association of Warfarin Control With Pulmonary Embolism Mortality: The CVRN VTE Study. Circulation, 2013, 128: A12186.Fang MC, Fan D, Witt DM et al. The Association of Warfarin Control With Pulmonary Embolism Mortality: The CVRN VTE Study. Circulation, 2013, 128: A12186.Erkens PM, ten Cate H, Büller HR, Prins MH. Benchmark for time in therapeutic range in venous thromboembolism: a systematic review and meta-analysis. PLoS One, 2012, 7: e42269.Erkens PM, ten Cate H, Büller HR, Prins MH. Benchmark for time in therapeutic range in venous thromboembolism: a systematic review and meta-analysis. PLoS One, 2012, 7: e42269.Douketis JD, Foster GA, Crowther MA et al. Clinical risk factors and timingof recurrent venous thromboembolism duringthe initial 3 months of anticoagulant therapy. Arch intern med, 2000. 160. 3431-3436.Douketis JD, Foster GA, Crowther MA et al. Clinical risk factors and timingof recurrent venous thromboembolism duringthe initial 3 months of anticoagulant therapy. Arch intern med, 2000. 160. 3431-3436.Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal, 2017 Jan, 70(1): 50. doi: 10.1016/j.rec.2016. 11.033.Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal, 2017 Jan, 70(1): 50. doi: 10.1016/j.rec.2016. 11.033.Российские клинические рекомендации «острый инфаркт миокарда с подъемом сегмента ST электрокардиограммы: реабилитация и вторичная профилактика». CardioСоматика, 2014, Приложение 1: 5-40.Российские клинические рекомендации «острый инфаркт миокарда с подъемом сегмента ST электрокардиограммы: реабилитация и вторичная профилактика». CardioСоматика, 2014, Приложение 1: 5-40.Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med, 2009, 361(24): 2342–2352.Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med, 2009, 361(24): 2342–2352.Schulman S, Kakkar AK, Goldhaber SZ, et al. Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis. Circulation, 2014, 129(7): 764–772.Schulman S, Kakkar AK, Goldhaber SZ, et al. Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis. Circulation, 2014, 129(7): 764–772.The EINSTEIN Investigators. Oral Rivaroxaban for Symptomatic Venous Thromboembolism. N Engl J Med, 2010, 363: 2499–2510.The EINSTEIN Investigators. Oral Rivaroxaban for Symptomatic Venous Thromboembolism. N Engl J Med, 2010, 363: 2499–2510.The EINSTEIN–PE Investigators. Oral Rivaroxaban for the Treatment of Symptomatic Pulmonary Embolism. N Engl J Med, 2012, 366: 1287–1297.The EINSTEIN–PE Investigators. Oral Rivaroxaban for the Treatment of Symptomatic Pulmonary Embolism. N Engl J Med, 2012, 366: 1287–1297.Prins MH, Lensing AWA, Bauersachs R et al. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J, 2013, 11: 21.Prins MH, Lensing AWA, Bauersachs R et al. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J, 2013, 11: 21.Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, Masiukiewicz U, Pak R, Thompson J, Raskob GE, Weitz JI; AMPLIFY Investigators. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med, 2013, 369: 799-808.Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, Masiukiewicz U, Pak R, Thompson J, Raskob GE, Weitz JI; AMPLIFY Investigators. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med, 2013, 369: 799-808.Es van J at al. Clot resolution after 3 weeks of anticoagulant treatment for pulmonary embolism: comparison of computed tomography and perfusion scintigraphy. Journal of Thrombosis and Haemostasis, 11: 679–685.Es van J at al. Clot resolution after 3 weeks of anticoagulant treatment for pulmonary embolism: comparison of computed tomography and perfusion scintigraphy. Journal of Thrombosis and Haemostasis, 11: 679–685.Российские клинические рекомендации по диагностике, лечению и профилактике венозных тромбоэмболических осложнений. Флебология, 2015, 4(вып. 2): 4-52.Российские клинические рекомендации по диагностике, лечению и профилактике венозных тромбоэмболических осложнений. Флебология, 2015, 4(вып. 2): 4-52.Kearon C, Akl EA, Ornelas J et al. Antithrombotic Therapy for VTE Disease CHEST Guideline and Expert Panel Report. CHEST, 2016, 149(2): 315-352.Kearon C, Akl EA, Ornelas J et al. Antithrombotic Therapy for VTE Disease CHEST Guideline and Expert Panel Report. CHEST, 2016, 149(2): 315-352.Spyropoulos AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Manag Care Pharm, 2007, 13: 475–486.Spyropoulos AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Manag Care Pharm, 2007, 13: 475–486.Margolis et al. Shorter Hospital Stays and Lower Costs for Rivaroxaban Compared With Warfarin for Venous Thrombosis Admissions. Journal of the American Heart Association, 2016, 5: e003788.Margolis et al. Shorter Hospital Stays and Lower Costs for Rivaroxaban Compared With Warfarin for Venous Thrombosis Admissions. Journal of the American Heart Association, 2016, 5: e003788.Barco S at al. Home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban. Rationale and design of the HoT-PE Trial. Thromb Haemost, 2016 Jul 4, 116(1): 191-7.Barco S at al. Home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban. Rationale and design of the HoT-PE Trial. Thromb Haemost, 2016 Jul 4, 116(1): 191-7.Счастливцев И.В., Лобастов К.В., Баринов В.Е. Эффективность и безопасность ривароксабана в сравнении с антагонистами витамина К при длительной терапии венозного тромбоза. Флебология, 2016, 10(1): 19-28.Счастливцев И.В., Лобастов К.В., Баринов В.Е. Эффективность и безопасность ривароксабана в сравнении с антагонистами витамина К при длительной терапии венозного тромбоза. Флебология, 2016, 10(1): 19-28.Mohsen Sharifi et al. Safe-Dose Thrombolysis Plus Rivaroxaban for Moderate and Severe Pulmonary Embolism: Drip, Drug, and Discharge. Clin. Cardiol., 2014, 37(2): 78–82.Mohsen Sharifi et al. Safe-Dose Thrombolysis Plus Rivaroxaban for Moderate and Severe Pulmonary Embolism: Drip, Drug, and Discharge. Clin. Cardiol., 2014, 37(2): 78–82.Papadakis E et al. DOACs dose adherence during initial and long term VTE management. Practical implications, findings from the RIETE registry. http://www.gth2017.org/en/showAbstract/546.Papadakis E et al. DOACs dose adherence during initial and long term VTE management. Practical implications, findings from the RIETE registry. http://www.gth2017.org/en/showAbstract/546.

The authors declare that there are no conflicts of interest present.