ACCP9抗栓指南更新点

ACCP新指南:并非所有患者适用DVT预防美国胸科医师学会（ACCP）最新指南《抗栓治疗和血栓形成预防临床实践指南（第9版）》推荐，决定使用或不使用深静脉血栓（DVT）和静脉血栓栓塞（VTE）预防性治疗时要考虑个别患者血栓形成风险。

该指南对患者风险进行分类，这提示临床医师在进行预防性治疗前应考虑患者DVT/VTE风险。

长途旅行的DVT/VTE风险因素研究虽然大多数患者不易出现旅行相关性深静脉血栓形成/静脉血栓栓塞，但指南支出，长途航班后，几种因素可能会增加个体DVT/VTE风险，包括既往DVT/VTE或已知的血栓形成性疾病；恶性肿瘤；近期手术或创伤;不活动；使用雌激素或怀孕；坐在靠窗的座位。

由于旅客的旅游相关性DVT / VTE风险升高，该指南建议应经常行走，拉伸小腿肌肉，如果可能的话坐在靠过道的座位，或使用膝盖下渐进性压力弹性袜即静脉曲张袜。

相反，该指南建议称，尚无确切证据显示脱水，饮酒，或坐经济舱可增加长途飞行对患者造成的DVT / VTE风险。

阿司匹林及新疗法预防DVT / VTE该指南还还对提出了有关使用新疗法或潜在疗法用于DVT / VTE预防和治疗的建议。

虽然阿司匹林用于DVT/VTE预防并不是什么新方法，但以前的ACCP指南反对在任何手术人群中使用阿司匹林单药进行预防性治疗。

最新版的治疗指南中，ACCP已对此进行了修订，并表示在大多数矫形手术中，阿司匹林也是预防DVT/VTE的一种选择，尽管其不是首选药物。

抗栓指南的创新《抗栓治疗和血栓形成预防临床实践指南（第9版）》包括显著影响血栓形成的预防，诊断和治疗的600多条建议的创新。

两个关键的进步是更加明确和定量的考虑对患者重要的指标和预后限定因素。

后者的创新引起血栓形成预防中对机体指标不同的解释，而以前曾重点监测无症状血栓。

资料来源：New Guidelines Suggest DVT Prophylaxis not Appropriate for All Patients.美国胸科医师学会，2012/02/07全文：New Guidelines Suggest DVT Prophylaxis not Appropriate for All PatientsArticle | 02.07.12(NORTHBROOK, IL, FEBRUARY 7, 2012) — New evidence-based guidelines from the American College of Chest Physicians (ACCP) recommend considering individual patients’risk of thrombosis when deciding for or against the use of preventive therapies for deep vein thrombosis (DVT) and venous thromboembolism (VTE). Specifically, the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, published in the February issue of the journal CHEST, focus on risk stratification of patients, suggesting clinicians should consider a patient’s risk for DVT/VTE and risk for bleeding before administering or prescribing a prevention therapy.“There has been a significant push in health care to administer DVT prevention for every patient, regardless of risk. As a result, many patients are receiving unnecessary therapies that provide little benefit and could have adverse effects,”said Guidelines Panel Chair Gordon Guyatt, MD, FCCP, Department of Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada. “The decision to administer DVT prevention therapy should be based on the patients’risk and the benefits of prevention or treatment.” To address this, the ACCP guidelines provide comprehensive risk stratification recommendations for most major clinical areas, including medical, nonorthopedic surgery, orthopedic surgery, pregnancy, cardiovascular disease, atrial fibrillation, stroke, pediatrics, and long-distance travel.DVT/VTE Risk Factors for Long-distance TravelAlthough developing a travel-related DVT/VTE is unlikely in most cases, the guidelines note that for long-distance flights, several factors may increase an individual’s risk of developing a DVT/VTE, including previous DVT/VTE or known thrombophilic disorder; malignancy; recent surgery or trauma; immobility; estrogen use or pregnancy; and sitting in a window seat. For travelers with an increased risk for travel-related DVT/VTE, the guidelines recommend frequent ambulation, calf muscle stretching, sitting in an aisle seat if possible, or the use of below-knee graduated compression stockings. Conversely, the guidelines suggest there is no definitive evidence to support that dehydration, alcohol intake, or sitting in economy class increases a patient’s risk for developing a DVT/VTE resulting from long-distance flights. Aspirin and New Therapies for DVT/VTE PreventionThe guidelines also provide recommendations related to the use of new or potential therapies for the prevention and treatment of DVT/VTE. Although aspirin is not a new therapy for the prevention of DVT/VTE, previous ACCP guidelines recommended against using aspirin as the single agent for prophylaxis in any surgical population. In the current edition, the ACCP has revised this recommendation and indicates aspirin is an option—although not typically the agent of choice—for the prevention of DVT/VTE in major orthopedic surgery.“Although we are not recommending aspirin as the optimal DVT/VTE prophylaxis, we have reviewed the existing evidence and concluded that aspirin is an acceptable option in some instances where preventive therapy is needed,”said guideline co-author Mark Crowther, MD, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. In regard to new oral anticoagulants, guideline authors recognize the recent clinical trials of apixaban and rivaroxaban, both direct factor Xa inhibitors, and dabigatran etexilate, a direct thrombin inhibitor, and offer recommendations for the new agents for select clinical conditions, including atrial fibrillation and orthopedic surgery.Innovations in Antithrombotic GuidelinesThe Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines include innovations that have significantly impacted the more than 600 recommendations for the prevention, diagnosis, and treatment of thrombosis. Two key advances are the more explicit and quantitative consideration of patient values and preferences and restriction of outcomes to only those deemed to be important for the patient. The latter innovation results in different interpretation of the body of evidence in thrombosis prevention that has previously focused on the detection of asymptomatic thrombosis by surveillance methods.Guideline authors also took a more critical look at the overall process of guideline development, providing more methodologically sophisticated scrutiny of all available evidence. “The evidence review for the new guidelines was more rigorous than ever before, and our method for grading research studies has become even more stringent,”said guideline co-author David Gutterman, MD, FCCP, ACCP Immediate Past President, Cardiovascular Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin. “We believe that the objective rigorous application of the science of guideline development will ultimately best serve our patients.”The guidelines are endorsed by the following medical associations: the American Association for Clinical Chemistry, American College of Clinical Pharmacy, American Society of Health-System Pharmacists, American Society of Hematology, International Society of Thrombosis and Hemostasis, and the American College of Obstetrics and Gynecology (pregnancy article only).For more information about the guidelines and accompanying clinician resources, visit and follow #AT9 on Twitter. Patient resources related to the guidelines are available through OneBreath®, an initiative of The CHEST Foundation, the philanthropic arm of the ACCP.About the American College of Chest PhysiciansThe ACCP represents 18,400 members who provide patient care in the areas of pulmonary, critical care, and sleep medicine in the United States and more than 100 countries throughout the world. The mission of the ACCP is to promote the prevention, diagnosis, and treatment of chest diseases through education, communication, and research. CHEST is the official peer-reviewed publication of the ACCP. More than 30,000 readers worldwide turn to CHEST in print and 400,000 people view CHEST online each month for the latest in chest-related medicine. For more information about the ACCP, visit or follow the ACCP via social media at /accpchest and @accpchest.。

2012 ACCP 抗栓治疗与血栓预防临床实践指南（第9 版）美国胸科医师协会（ACCP ）于2012 年 2 月7 日公布了第9 版《抗栓与血栓预防》临床实践指南，发表于《胸》杂志的增刊：Chest 2012, 141 （ 2 Suppl ）。

与上一版指南（2008 年发布）相比，新版指南更为简洁明了，首次加入了关于深静脉血栓形成（DVT）的诊断章节。

指南目录1、Disclaimer2、Panel List3、Executive Summary （执行摘要）4、Introduction to the Ninth Edition （第九版简介）点击下载全文5、Methodology for the Development of AntithromboticTherapy and Prevention of Thrombosis Guidelines （抗栓和溶栓治疗指南制定方法）点击下载全文6、Patient Values and Preferences in DecisionMaking for Antithrombotic Therapy （抗凝治疗决策中的患者评估和参数）点击下载全文7、Parenteral Anticoagulants （肠外抗凝治疗）点击下载全文8、Oral Anticoagulant Therapy （口服抗凝药的使用）点击下载全文9、Antiplatelet Drugs（抗血小板药物）点击下载全文10、New Antithrombotic Drugs （抗栓新药）点击下载全文11、Evidence-Based Management of AnticoagulantTherapy（抗栓治疗管理的循证基础）点击下载全文12、Approach to Outcome Measurement in thePrevention of Thrombosis in Surgical and MedicalPatients （外科治疗患者预防血栓形成预后管理措施）点击下载全文13、Prevention of VTE in Nonsurgical Patients（非手术患者的VTE 预防）点击下载全文14、Prevention of VTE in Nonorthopedic SurgicalPatients（非骨科手术的VTE 预防）点击下载全文15、Prevention of VTE in Orthopedic Surgery Patients （骨科手术患者的VTE 预防）点击下载全文16、Perioperative Management of Antithrombotic Therapy （围手术期的抗栓治疗管理）点击下载全文17 、Diagnosis of DVT （深静脉血栓形成的诊断）点击下载全文18、Antithrombotic Therapy for VTE Disease （静脉血栓栓塞性疾病的抗栓治疗）点击下载全文19、Treatment and Prevention of Heparin-Induced Thrombocytopenia（肝素诱导的血小板减少症的治疗与预防）点击下载全文20、Antithrombotic Therapy for AtrialFibrillation（房颤的抗栓治疗）点击下载全文21、Antithrombotic and Thrombolytic Therapy for Valvular Disease（心瓣膜病的抗栓和溶栓治疗）点击下载全文22、Antithrombotic and Thrombolytic Therapy for Ischemic Stroke（缺血性卒中的抗栓和溶栓治疗）点击下载全文23、Primary and Secondary Prevention of Cardiovascular Disease（心血管疾病的一级和二级预防）点击下载全文24 、Antithrombotic Therapy in Peripheral Artery Disease（周围动脉疾病的抗栓治疗）点击下载全文25、VTE, Thrombophilia, Antithrombotic Therapy, andPregnancy（静脉血栓栓塞、血栓形成倾向、抗栓治疗与妊娠）点击下载全文26 、Antithrombotic Therapy in Neonates and Children（新生儿和儿童的抗栓治疗）点击下载全文更多内容请点击：DVT 病因新指南:经济舱综合征缺乏证据ACCP 新指南:并非所有患者适用DVT 预防另外，非常感谢fxjj 医友为大家提供该指南的部分内容，期待在大家共同努力下，能在该频道分享到更多更新的指南温馨提示：由于该指南的内容较为丰富，文档较多（共26 个文档），所以，完整指南内容包括了附件中的 3 个压缩包和2 个pdf 文档。

DOI 10.1378/chest.1412S3 2012;141;7S-47S ChestPhysicians Antithrombotic Therapy and Prevention of Thrombosis Panel Holger J. Schuünemann and for the American College of ChestGordon H. Guyatt, Elie A. Akl, Mark Crowther, David D. Gutterman,Evidence-Based Clinical Practice Guidelinesed: American College of Chest Physicians Therapy and Prevention of Thrombosis, 9th Executive Summary : Antithrombotic/content/141/2_suppl/7S.full.html services can be found online on the World Wide Web at:The online version of this article, along with updated information and7S.DC1.html/content/suppl/2012/02/06/141.2_suppl.Supplemental material related to this article is available at:ISSN:0012-3692)/site/misc/reprints.xhtml (written permission of the copyright holder.this article or PDF may be reproduced or distributed without the prior Dundee Road, Northbrook, IL 60062. All rights reserved. No part of Copyright2012by the American College of Chest Physicians, 3300Physicians. It has been published monthly since 1935.is the official journal of the American College of Chest ChestCHEST / 141 / 2 / FEBRUARY , 2012 SUPPLEMENT 7ST he eighth iteration of the American College of Chest Physicians Antithrombotic Guidelines pre-sented, in a paper version, a narrative evidence sum-mary and rationale for the recommendations, a small number of evidence profi les summarizing bodies ofevidence, and some articles with quite extensivesummary tables of primary studies. In total, this represented 600 recommendations summarized in 968 pages of text. Many readers responded that the result was too voluminous for their liking or prac-tical use. C ognizant of this feedback, we worked hard to minimize the length of the text for the ninth iteration of the guidelines Antithrombotic Therapy and Pre-vention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (AT9) without sacrifi cing key content. A number of topic editors found our shortening edits draconian, but we were determined to produce the leanest product possible.T here were, however, a number of obstacles. In what we believe is a key advance in AT9, we con-ducted a systematic review of what is known about patients’ values and preferences regarding antithrom-botic therapy and included the results as an article in AT9. In another forward step, we recognized the problems with asymptomatic thrombosis as a surro-gate outcome, and devised strategies to estimate reductions in symptomatic DVT and pulmonary embolism with antithrombotic prophylaxis. We felt it important to explain this innovation to users of AT9, and this meant another article. W e included, for the fi rst time, an article on diag-nosis addressing patients with symptoms and signs suggesting DVT. We increased the range of interven-tions we have covered, resulting in additional recom-mendations. Finally, we produced many summary of fi ndings tables, which offer extremely succinct and informative presentations of best estimates of effect and the confi dence associated with those estimates.I f published in the same fashion as the Antithrom-botic and Thrombolytic Therapy, 8th ed: AmericanA bbreviations:ACS 5 acute coronary syndrome; AF 5 atrialfi brillation; AIS 5 arterial ischemic stroke; APLA 5antiphospolipidantibodies; ASA 5 acetylsalicylic acid; AT9 5 Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines; BMS 5 bare-metal stent; CABG 5 coronary artery bypass graft; CAD 5coronary artery disease; CDT 5catheter-directed thrombosis; CHADS 2 5 congestive heart failure, hyperten-sion, age Ն 75 years, diabetes mellitus, prior stroke or transient ischemic attack; CSVT 5 cerebral sinovenous thrombosis; CTPH 5 chronic thromboembolic pulmonary hypertension; CUS 5 com-pression ultrasound; CVAD 5 central venous access device; DES 5 d rug-eluting stent; GCS 5 g raduated compression stockings; H FS 5 hip fracture surgery; HIT 5 heparin-induced thrombocy-topenia; HITT 5 heparin-induced thrombocytopenia complicated by thrombosis; IA 5 intraarterial; ICH 5intracerebral hemor-rhage; IE 5 infective endocarditis; INR 5 international normalized ratio; IPC 5 intermittent pneumatic compression; IPCD 5 inter-mittent pneumatic compression device; IVC 5 inferior vena cava; LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular-weight heparin; LV 5 left ventricular; MBTS 5 modifi ed Blalock-Taussig shunt; MR 5 magnetic resonance; PAD 5peripheral artery disease; PCI 5 percutaneous coronary inter v ention; PE 5 pul-monary embolism; PFO 5 patent foramen ovale; PMBV 5 p ercuta-neous mitral balloon valvotomy; PTS 5postthrombotic syndrome; PVT 5 prosthetic valve thrombosis; r-tPA 5 recombinant tissue plas-minogen activator; RVT 5 renal vein thrombosis; SC 5 subcuta-neous; TEE 5 transesophageal echocardiography; THA 5 total hip arthroplasty; TIA 5 transient ischemic attack; TKA 5 total knee arthroplasty; UAC 5umbilical arterial catheter; UEDVT 5 upper-extremity DVT; UFH 5 unfractionated heparin; US 5 ultrasound; UVC 5 umbilical venous catheter; VAD 5 ventricular assist device; VKA 5 vitamin K antagonistAntithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice GuidelinesG ordon H. G uyatt ,M D, FCCP ;E lie A. A kl ,M D, PhD, M PH ;M ark C rowther ,M D ;D avid D. G utterman ,M D, FCCP ;H olger J. S chü n emann ,M D, PhD, FCCP ;f or the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel *CHEST 2012; 141(2)(Suppl):7S–47S8SExecutive Summarytables) and some tables summarizing the methodsand results, and the risk of bias, associated with the individual studies that contributed to the evidence profi les and summary of fi ndings tables.T he world of medical information is rapidly becom-ing a world of electronic storage and presentation of primary studies, recommendations, and a wide variety of other information of interest to health care prac t itioners. Although our abbreviated paper copy presentation represents a necessary response to a challenging situation, it is also a harbinger of the increasingly electronic world of medical information into which future editions of guidelines are destined to move.S ummary of Recommendations Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommenda-tions sections to indicate recommendations that are newly added or have been changed since the publica-tion of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Rec-ommendations that remain unchanged are not shaded.E vidence-Based Management of Anticoagulant TherapyF or further details, see Holbrook et al. 1 2.1 Loading Dose for Initiation of Vitamin K Antagonist(VKA) Therapy2.1. For patients suffi ciently healthy to be treated as outpatients, we suggest initiating VKA therapy with warfarin 10 mg daily for the fi rst 2 days followed by dosing based on international normalized ratio (INR) measurements rather than starting with the estimated maintenance dose (Grade 2C) .2.2 Initial Dose Selection and Pharmacogenetic Testing2.2. For patients initiating VKA therapy, we recommend against the routine use of pharma-cogenetic testing for guiding doses of VKA (Grade 1B) . 2.3 Initiation Overlap for Heparin and VKA2.3. For patients with acute VTE, we suggest that VKA therapy be started on day 1 or 2 of low-molecular-weight heparin (LMWH) or low-dose unfractionated heparin (UFH) therapy rather than waiting for several days to start (Grade 2C) .College of Chest Physicians Antithrombotic Guide-lines, this would have resulted in a document with . 850 pages of paper text, an unacceptable length. Given this and with the advice of the journal, we decided to adopt a highly focused print version that includes only this executive summary and the following articles:• An introduction describing the major innovations in AT9 • A methods article explaining how we devel-oped the guidelines (a potential model for other guideline groups interested in optimal rigor) • Recommendations and grading from each arti-cle embedded in the table of contents of each article T hose seeking the rationale for the recommenda-tions, including the supporting evidence, should access the online version of the guideline ( h ttp:///content/141/2_suppl )that includes a narrative summaries and support-ing summary of fi ndings tables. The numbering indi-cated beside the recommendations in this summary is aligned with the sections and tables found in the full articles. Those interested in a deeper under-standing of the evidence can turn to online data supplements for each of the articles that include rec-ommendations. There, they will fi nd evidence pro-fi les (expanded versions of the summary of fi ndingsR evision accepted August 31, 2011. A ffi liations: From the Department of Clinical Epidemiology and Biostatistics (Drs Guyatt, Akl, and Schü n emann) and Depart-ment of Medicine (Drs Guyatt, Crowther, and Schü n emann), McMaster University Faculty of H ealth Sciences, H amilton, ON, Canada; Departments of Medicine and Family Medicine (Dr Akl), State University of New York, Buffalo, NY; Cardiovascular Research Center (Dr Gutterman), Medical College of Wisconsin, Milwaukee, WI.*For complete panel list, see: /content/141/2_suppl/2S F unding/Support : The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educa-tional grants were also provided by Bristol-Myers Squibb; Pfi zer, Inc; Canyon Pharmaceuticals; and sanofi -aventis US.D isclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at /content/141/2_suppl/1SC orrespondence to: Gordon H . Guyatt, MD, FCCP , Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8N 3Z5, Canada; e-mail: guyatt@mcmaster.ca© 2012 American College of Chest Physicians.Reproduction of this article is prohibited without written permission from the American College of Chest Physicians ( h ttp:///site/misc/reprints.xhtml ).D OI: 10.1378/chest.1412S3CHEST / 141 / 2 / FEBRUARY , 2012 SUPPLEMENT 9S3.8 VKA Drug Interactions to Avoid3.8. For patients taking VKAs, we suggest avoid-ing concomitant treatment with nonsteroidal antiinfl ammatory drugs, including cyclooxyge-nase-2-selective nonsteroidal antiinfl ammatory drugs, and certain antibiotics (see Table 8 in mainarticle1 ) (Grade 2C) .F or patients taking VKAs, we suggest avoiding concomitant treatment with antiplatelet agents except in situations where benefi t is known or is highly likely to be greater than harm from bleeding, such as patients with mechanical valves, patients with acute coronary syndrome, or patients with recent coronary stents or bypass surgery (Grade 2C) .4.1 Optimal Therapeutic INR Range4.1. For patients treated with VKAs, we recom-mend a therapeutic INR range of 2.0 to 3.0 (tar-get INR of 2.5) rather than a lower (INR , 2) or higher (INR 3.0-5.0) range (Grade 1B) . 4.2 Therapeutic Range for High-Risk Groups 4.2. For patients with antiphospholipid syn d rome with previous arterial or venous thromboembolism, we suggest VKA therapy titrated to a moderate-intensity INR range (INR 2.0-3.0) rather than higher intensity (INR 3.0-4.5) (Grade 2B). 5.0 Discontinuation of Therapy5.0. For patients eligible to discontinue treat-ment with VKA, we suggest abrupt discontinua-tion rather than gradual tapering of the dose to discontinuation (Grade 2C) .6.1 Unfractionated Heparin (UFH) Dose Adjustment by Weight6.1. For patients starting IV UFH, we suggest that the initial bolus and the initial rate of the continuous infusion be weight adjusted (bolus 80 units/kg followed by 18 units/kg per h for VTE; bolus 70 units/kg followed by 15 units/kg per h for cardiac or stroke patients) or use of a fi xed dose (bolus 5,000 units followed by 1,000 units/h) rather than alternative regimens (Grade 2C) . 6.2 Dose Management of Subcutaneous (SC) UFH6.2. For outpatients with VTE treated with SC UFH, we suggest weight-adjusted dosing (fi rst dose 333 units/kg, then 250 units/kg) with-out monitoring rather than fi xed or weight-adjusted dosing with monitoring (Grade 2C) .3.1 Monitoring Frequency for VKAs3.1. For patients taking VKA therapy with con-sistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks (Grade 2B) .3.2 Management of the Single Out-of-Range INR3.2. For patients taking VKAs with previously stable therapeutic INRs who present with a single out-of-range INR of Յ 0.5 below or above therapeutic, we suggest continuing the current dose and testing the INR within 1 to 2 weeks (Grade 2C) .3.3 Bridging for Low INRs3.3. For patients with stable therapeutic INRs presenting with a single subtherapeutic INR value, we suggest against routinely adminis-tering bridging with heparin (Grade 2C) . 3.4 Vitamin K Supplementation3.4. For patients taking VKAs, we suggest against routine use of vitamin K supplementa-tion (Grade 2C) .3.5 Anticoagulation Management Services for VKAs 3.5. (Best Practices Statement) We suggest that health-care providers who manage oral antico-agulation therapy should do so in a systematic and coordinated fashion, incorporating patient education, systematic INR testing, tracking, follow-up, and good patient communication of results and dosing decisions.3.6 Patient Self-Testing and Self-Management3.6. For patients treated with VKAs who are motivated and can demonstrate competency in self-management strategies, including the self-testing equipment, we suggest patient self-management rather than usual outpatient INR monitoring (Grade 2B) . For all other patients, we suggest monitoring that includes the safe-guards in our best practice statement 3.5. 3.7 Dosing Decision Support3.7. For dosing decisions during maintenance VKA therapy, we suggest using validated deci-sion support tools (paper nomograms or com-puterized dosing programs) rather than no decision support (Grade 2C) .Remarks: Inexperienced prescribers may be more likely to improve prescribing with use of decision sup-port tools than experienced prescribers.10SExecutive Summaryunfractionated heparin (L DUH) bid, LDUHtid, or fondaparinux (Grade 1B) .R emarks: In choosing the specifi c anticoagulant drug to be used for pharmacoprophylaxis, choices should be based on patient preference, compliance, and ease of administration (eg, daily vs bid vs tid dosing), as well as on local factors affecting acquisition costs (eg, prices of various pharmacologic agents in individual hospital formularies).2.4. For acutely ill hospitalized medical patients at low risk of thrombosis, we recommend against the use of pharmacologic prophylaxis or mechan-ical prophylaxis (Grade 1B) .2.7.1. For acutely ill hospitalized medical patients who are bleeding or at high risk for bleeding, we recommend against anticoagulant thromboprophylaxis (Grade 1B) .2.7.2. For acutely ill hospitalized medical patients at increased risk of thrombosis who are bleeding or at high risk for major bleeding, we suggest the optimal use of mechanical thromboprophylaxis with graduated compression stockings (GCS) (Grade 2C) or intermittent pneumatic compres-sion (IPC) (Grade 2C) , rather than no mechan-ical thromboprophylaxis. When bleeding risk decreases, and if VTE risk persists, we sug-gest that pharmacologic thromboprophylaxis be substituted for mechanical thromboprophy-laxis (Grade 2B) .R emarks: Patients who are particularly averse to the potential for skin complications, cost, and need for clinical monitoring of GCS and IPC use are likely to decline mechanical prophylaxis.2.8. In acutely ill hospitalized medical patients who receive an initial course of thrombopro-phylaxis, we suggest against extending the dura-tion of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay (Grade 2B) .3.0 Critically Ill Patients3.2. In critically ill patients, we suggest against routine ultrasound screening for DVT (Grade 2C) .3.4.3. For critically ill patients, we suggest using LMWH or LDUH thromboprophylaxis over no prophylaxis (Grade 2C) .3.4.4. For critically ill patients who are bleeding, or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with GCS (Grade 2C) o r IPC (Grade 2C) u ntil the7.1 Therapeutic Dose of LM WH in Patients With Decreased Renal Function7.1. For patients receiving therapeutic LMWH who have severe renal insuffi ciency (calculated creatinine clearance , 30 mL/min), we suggest a reduction of the dose rather than using stan-dard doses (Grade 2C) .8.1 Fondaparinux Dose Management by Weight8.1. For patients with VTE and body weight over 100 kg, we suggest that the treatment dose of fondaparinux be increased from the usual 7.5 mg to 10 mg daily SC (Grade 2C) .9.1 Vitamin K for Patients Taking VKAs With High INRs Without Bleeding9.1.(a) For patients taking VKAs with INRs between 4.5 and 10 and with no evidence of bleeding, we suggest against the routine use of vitamin K (Grade 2B) .(b) For patients taking VKAs with INRs . 10.0 and with no evidence of bleeding, we suggest that oral vitamin K be administered (Grade 2C) . 9.2 Clinical Prediction Rules for Bleeding While Taking VKA9.2. For patients initiating VKA therapy, we suggest against the routine use of clinical pre-diction rules for bleeding as the sole criterion to withhold VKA therapy (Grade 2C) .9.3 Treatment of Anticoagulant-Related Bleeding9.3. For patients with VKA-associated major bleeding, we suggest rapid reversal of antico-agulation with four-factor prothrombin complex concentrate rather than with plasma. (Grade 2C) .W e suggest the additional use of vitamin K 5 to 10 mg administered by slow IV injection rather than reversal with coagulation factors alone (Grade 2C) .P revention of VTE in Nonsurgical PatientsF or further details, see Kahn et al. 2 2.0 Hospitalized Acutely Ill Medical Patients2.3. For acutely ill hospitalized medical patients at increased risk of thrombosis, we recom m end anticoagulant thromboprophylaxis with low-molecular-weight heparin [LMWH], low-doseCHEST / 141 / 2 / FEBRUARY , 2012 SUPPLEMENT 11Sknee GCS providing 15 to 30 mm Hg of pressureat the ankle during travel (Grade 2C) . F or all other long-distance travelers, we suggest against the use of GCS (Grade 2C) .6.1.3. For long-distance travelers, we suggest against the use of aspirin or anticoagulants to prevent VTE (Grade 2C) .7.0 Persons With Asymptomatic Thrombophilia7.1. In persons with asymptomatic thrombo-philia (ie, without a previous history of VTE), we recommend against the long-term daily use of mechanical or pharmacologic thrombopro-phylaxis to prevent VTE (Grade 1C) .P revention of VTE in Nonorthopedic Surgical PatientsF or further details, see Gould et al. 3 3.6 Patients Undergoing General, GI, Urological,Gynecologic, Bariatric, Vascular, Plastic, or Recon-structive Surgery3.6.1. For general and abdominal-pelvic sur-gery patients at very low risk for VTE ( , 0.5%; Rogers score, , 7; Caprini score, 0), we recom-mend that no specifi c pharmacologic (Grade 1B) o r mechanical (Grade 2C) p rophylaxis be used other than early ambulation.3.6.2. For general and abdominal-pelvic sur-gery patients at low risk for VTE ( ف 1.5%; Rog-ers score, 7-10; Caprini score, 1-2), we suggest mechanical prophylaxis, preferably with inter-mittent pneumatic compression (IPC), over no prophylaxis (Grade 2C) .3.6.3. For general and abdominal-pelvic sur-gery patients at moderate risk for VTE ( ف 3.0%; Rogers score, . 10; Caprini score, 3-4) who are not at high risk for major bleeding complica-tions, we suggest L MWH (Grade 2B ), L DUH (Grade 2B) , o r mechanical prophylaxis, prefer-ably with IPC (Grade 2C) ,o ver no prophylaxis. R emarks: T hree of the seven authors favored a strong (Grade 1B) recommendation in favor of LMWH or LDUH over no prophylaxis in this group.3.6.4. For general and abdominal-pelvic sur-gery patients at moderate risk for VTE (3.0%; Rogers score, . 10; Caprini score, 3-4) who are at high risk for major bleeding complications or those in whom the consequences of bleed-ing are thought to be particularly severe, webleeding risk decreases, rather than no mechan-ical thromboprophylaxis. When bleeding risk decreases, we suggest that pharmacologic throm-boprophylaxis be substituted for mechanical thromboprophylaxis (Grade 2C) . 4.0 Patients With Cancer in the Outpatient Setting4.2.1. In outpatients with cancer who have no additional risk factors for VTE, we suggest against routine prophylaxis with L MWH or LDUH (Grade 2B) and recommend against the prophylactic use of VKAs (Grade 1B) .R emarks: Additional risk factors for venous throm-bosis in cancer outpatients include previous venous thrombosis, immobilization, hormonal therapy, angio-genesis inhibitors, thalidomide, and lenalidomide.4.2.2. In outpatients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic-dose L MWH or L DUH over no prophylaxis (Grade 2B) .R emarks: Additional risk factors for venous thrombo-sis in cancer outpatients include previous venous thrombosis, immobilization, hormonal therapy, angio-genesis inhibitors, thalidomide, and lenali d omide.4.4. In outpatients with cancer and indwelling central venous catheters, we suggest againstroutine prophylaxis with L MWH or L DUH (Grade 2B) and suggest against the prophylactic use of VKAs (Grade 2C) .5.0 Chronically Immobilized Patients5.1. In chronically immobilized persons residing at home or at a nursing home, we suggest against the routine use of thromboprophylaxis (Grade 2C) .6.0 Persons Traveling Long-Distance6.1.1. For long-distance travelers at increased risk of VTE (including previous VTE, recent surgery or trauma, active malignancy, preg-nancy, estrogen use, advanced age, limited mobility, severe obesity, or known thrombo-philic disorder), we suggest frequent ambula-tion, calf muscle exercise, or sitting in an aisle seat if feasible (Grade 2C) .6.1.2. For long-distance travelers at increased risk of VTE (including previous VTE, recent surgery or trauma, active malignancy, pregnancy, estrogen use, advanced age, limited mobility, severe obesity, or known thrombophilic disor-der), we suggest use of properly fi tted, below-12SExecutive Summarygest use of mechanical prophylaxis, preferably with optimally applied IPC, over either no pro-phylaxis (Grade 2C) o r pharmacologic prophy-laxis (Grade 2C) .4.4.2. For cardiac surgery patients whose hos-pital course is prolonged by one or more non-hemorrhagic surgical complications, we suggest adding pharmacologic prophylaxis with LDUH or LMWH to mechanical prophylaxis (Grade 2C) .5.0 Patients Undergoing Thoracic Surgery5.4.1. For thoracic surgery patients at mod-erate risk for VTE who are not at high risk for perioperative bleeding, we suggest L DUH (Grade 2B) , L MWH (Grade 2B) , o r mechanical prophylaxis with optimally applied IPC (Grade 2C)o ver no prophylaxis. R emarks: T hree of the seven authors favored a strong (Grade 1B) recommendation in favor of LMWH or LDUH over no prophylaxis in this group.5.4.2. For thoracic surgery patients at high risk for VTE who are not at high risk for periopera-tive bleeding, we suggest LDUH (Grade 1B) o r LMWH (Grade 1B) o ver no prophylaxis. In addi-tion, we suggest that mechanical prophylaxis with elastic stockings or IPC should be added to pharmacologic prophylaxis (Grade 2C) .5.4.3. For thoracic surgery patients who are at high risk for major bleeding, we suggest use of mechanical prophylaxis, preferably with opti-mally applied IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C) .6.0 Patients Undergoing Craniotomy6.4.1. For craniotomy patients, we suggest that mechanical prophylaxis, preferably with IPC, be used over no prophylaxis (Grade 2C) o r phar-macologic prophylaxis (Grade 2C) .6.4.2. For craniotomy patients at very high risk for VTE (eg, those undergoing craniotomy for malignant disease), we suggest adding pharma-cologic prophylaxis to mechanical prophylaxis once adequate hemostasis is established and the risk of bleeding decreases (Grade 2C) .7.0 Patients Undergoing Spinal Surgery7.4.1. For patients undergoing spinal surgery, we suggest mechanical prophylaxis, prefer-ably with IPC, over no prophylaxis (Grade 2C) , u nfractionated heparin (Grade 2C) , o r LMWH (Grade 2C) .suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis (Grade 2C) .3.6.5. For general and abdominal-pelvic sur-gery patients at high risk for VTE ( ف 6.0%; Caprini score, Ն 5) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) o r L DUH (Grade 1B) o ver no prophylaxis. We suggest that mechanical prophylaxis with elastic stockings or IPC should be added to phar-macologic prophylaxis (Grade 2C) .3.6.6. For high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding complications, we recommend extended-duration pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B) .R emarks: Patients who place a high value on mini-mizing out-of-pocket health-care costs might prefer limited-duration over extended-duration prophylaxis in settings where the cost of extended-duration pro-phylaxis is borne by the patient.3.6.7. For high-VTE-risk general and abdominal-pelvic surgery patients who are at high risk for major bleeding complications or those in whom the consequences of bleeding are thought to be particularly severe, we suggest use of mechan-ical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C) .3.6.8. For general and abdominal-pelvic sur-gery patients at high risk for VTE (6%; Caprini score, Ն 5) in whom both L MWH and unfrac-tionated heparin are contraindicated or unavail-able and who are not at high risk for major bleeding complications, we suggest low-dose aspirin (Grade 2C) , f ondaparinux (Grade 2C) , o r mechanical prophylaxis, preferably with IPC (Grade 2C) ,o ver no prophylaxis.3.6.9. For general and abdominal-pelvic sur-gery patients, we suggest that an inferior vena cava (IVC) fi lter should not be used for primary VTE prevention (Grade 2C) .3.6.10. For general and abdominal-pelvic surgery patients, we suggest that periodic surveillance with venous compression ultrasound should not be performed (Grade 2C) .4.0 Patients Undergoing Cardiac Surgery4.4.1. For cardiac surgery patients with an uncomplicated postoperative course, we sug-CHEST / 141 / 2 / FEBRUARY , 2012 SUPPLEMENT 13Sigatran, rivaroxaban, low-dose unfractionatedheparin (LDUH), adjusted-dose VKA, aspirin (all Grade 1B) , or an intermittent pneumatic com-pression device (IPCD) (Grade 1C) .R emarks: We recommend the use of only portable, battery-powered IPCDs capable of recording and reporting proper wear time on a daily basis for inpa-tients and outpatients. Efforts should be made to achieve 18 h of daily compliance. One panel member believed strongly that aspirin alone should not be included as an option.2.1.2. In patients undergoing HFS, we recom-mend use of one of the following rather than no antithrombotic prophylaxis for a minimum of 10 to 14 days: L MWH, fondaparinux, L DUH, adjusted-dose VKA, aspirin (all Grade 1B) , or an IPCD (Grade 1C) .R emarks: We recommend the use of only portable, battery-powered IPCDs capable of recording and reporting proper wear time on a daily basis for inpa-tients and outpatients. Efforts should be made to achieve 18 h of daily compliance. One panel member believed strongly that aspirin alone should not be included as an option.2.2. For patients undergoing major orthopedic surgery (THA, TKA, HFS) and receiving LMWH as thromboprophylaxis, we recommend starting either 12 h or more preoperatively or 12 h or more postoperatively rather than within 4 h or less pre-operatively or 4 h or less postoperatively (Grade 1B) .2.3.1. In patients undergoing THA or TKA, irrespective of the concomitant use of an IPCD or length of treatment, we suggest the use of L MWH in preference to the other agents we have recommended as alternatives: fonda-parinux, apixaban, dabigatran, rivaroxaban, LDUH (all Grade 2B) , adjusted-dose VKA, or aspirin (all Grade 2C) .R emarks: If started preoperatively, we suggest admin-istering LMWH Ն 12 h before surgery. Patients who place a high value on avoiding the inconvenience of daily injections with LMWH and a low value on the limitations of alternative agents are likely to choose an alternative agent. Limitations of alter-native agents include the possibility of increased bleeding (which may occur with fondaparinux, rivar-oxaban, and VKA), possible decreased effi cacy (LDUH, VKA, aspirin, and IPCD alone), and lack of long-term safety data (apixaban, dabigatran, and rivaroxaban). Furthermore, patients who place a high value on avoiding bleeding complications and a low value on7.4.2. For patients undergoing spinal surgery at high risk for VTE (including those with malig-nant disease or those undergoing surgery with a combined anterior-posterior approach), we suggest adding pharmacologic prophylaxis to mechanical prophylaxis once adequate hemo-stasis is established and the risk of bleeding decreases (Grade 2C) . 8.0 Patients With Major Trauma: Traumatic Brain Injury, Acute Spinal Injury, and Traumatic Spine Injury8.4.1. For major trauma patients, we suggest use of LDUH (Grade 2C) , L MWH (Grade 2C) , o r mechanical prophylaxis, preferably with IPC (Grade 2C) ,o ver no prophylaxis.8.4.2. For major trauma patients at high risk for VTE (including those with acute spinal cord injury, traumatic brain injury, and spinal sur-gery for trauma), we suggest adding mechan-ical prophylaxis to pharmacologic prophylaxis (Grade 2C) w hen not contraindicated by lower-extremity injury.8.4.3. For major trauma patients in whom LMWH and LDUH are contraindicated, we sug-gest mechanical prophylaxis, preferably with IPC, over no prophylaxis (Grade 2C) w hen not contraindicated by lower-extremity injury. We suggest adding pharmacologic prophylaxis with either L MWH or L DUH when the risk of bleeding diminishes or the contraindication to heparin resolves (Grade 2C) .8.4.4. For major trauma patients, we suggest that an IVC fi lter should not be used for pri-mary VTE prevention (Grade 2C) .8.4.5. For major trauma patients, we suggest that periodic surveillance with venous compression ultrasound should not be performed (Grade 2C) .P revention of VTE in Orthopedic Surgery PatientsF or further details, see Falck-Ytter et al. 4 2.0 Patients Undergoing Major Orthopedic Surgery: Total Hip Arthroplasty (THA), Total Knee Arthroplasty (TKA), Hip Fracture Surgery (HFS)2.1.1. In patients undergoing THA or TKA, we recommend use of one of the following for a minimum of 10 to 14 days rather than no anti-thrombotic prophylaxis: low-molecular-weight heparin (LMWH), fondaparinux, apixaban, dab-。

美国抗栓指南第九版（有关氯吡格雷介绍）近日，美国胸内科医师学会（ACCP）在《胸》（Chest 2012，141：7S-47S）杂志公布了第9版《抗栓治疗及预防血栓形成指南》（ACCP-9）。

此版指南在第8版基础上，结合最新循证医学证据，对抗栓治疗进行了全面细致的推荐。

这里剪切指南里面有关氯吡格雷的介绍。

CHEST：第9版《美国胸科医师协会抗栓与血栓预防临床实践指南》之心血管疾病的初级和二级预防对于已确诊为冠心病（即急性冠脉综合征后1年）、先前有冠脉血管重建、冠脉造影提示冠脉狭窄>50%，和（或）有心肌缺血诊断依据的患者，推荐长期低剂量阿司匹林或氯吡格雷（75mg/d）治疗（证据1A）。

对于行经皮冠状动脉介入治疗（PCI）支架置入术的急性冠脉综合征患者，推荐第一年低剂量阿司匹林联合替卡格雷（90mg每日2次）或氯吡格雷（75mg/d）或普拉格雷（10mg/d）双联抗血小板治疗优于单一抗血小板药物治疗（证据 1B）。

对于择期行PCI和支架置入的患者，推荐阿司匹林（75-325mg/d）联合氯吡格雷治疗，若选择裸金属治疗，用药时间至少为1个月，若选药物涂层支架，用药时间至少为3-6个月（证据1A）。

并推荐所有支架植入患者连续使用低剂量阿司匹林联合氯吡格雷12个月（证据 2C）。

12个月以后，推荐单一抗血小板药物治疗优于双联抗血小板治疗（证据 1B）。

据此得出结论，对于确诊为冠心病的患者，推荐单一抗血小板药物治疗；对于急性冠脉综合征患者或择期行PCI支架置入术的患者，双联抗血小板药物治疗长达1年是必需的。

CHEST：第9版《ACCP临床实践指南》之缺血性卒中的抗栓和溶栓治疗对于有非心源性栓子（即动脉粥样硬化血栓形成性、腔隙性或隐源性）所致缺血性卒中或ＴＩＡ病史的患者，推荐长期使用抗血小板药物治疗，以下治疗方案均可选用：阿司匹林（剂量为75-100mg，每日一次)，氯吡格雷（剂量为75mg，每日一次），阿司匹林加缓释双嘧达莫（剂量分别为25mg，每日2次和200mg，每日2次）或西洛他唑（剂量为100mg，每日2次）。

ACCP抗栓溶栓治疗指南解读（全文）血栓形成或栓塞是导致心、脑和外周血管事件的最后关键环节，是致死和致残的直接原因，没有血栓就没有事件。

目前，我们正面临血栓栓塞性疾病的巨大挑战。

美国心脏病学会2004年初发布的最新统计学资料表明，动脉粥样硬化仍为美国的头号杀手。

静脉血栓栓塞性疾病和心房颤动的患病率逐年增加，将带来巨大的卫生和经济负担。

但目前国内对血栓栓塞性疾病的诊治存在不规范、不合理的地方，如对动脉和静脉血栓栓塞的基础理论知识欠缺，不同性质血栓选择不同的药物以及用药方法不规范或无选择的大量实施导管、滤器等有创治疗手段。

同此，迫切需要应用科学的指南来规范医疗行为。

在此，将结合ACCP最新的抗栓和溶栓指南，针对国内目前存在的问题，讨论静脉、动脉和心房颤动血栓栓塞预防的重要进展。

一、静脉血栓栓塞（VTE）的预防一例静脉血栓栓塞的直接住院治疗费用相当于一例心肌梗死或卒中的直接住院治疗费用，一例深静脉血栓附加的长期医疗保健费用多于初期费用的75％。

血栓栓塞性疾病一旦发生，后果严重，VTE的干预策略应该重在预防，而有效的预防依赖于医生对疾病的高度认知和危险人群的识别和预防性抗凝治疗。

静脉血栓栓塞预防涉及的领域越来越广，增加了血管外科、腔镜手术、膝关节术、长途旅行等相关的内容。

除了传统的抗凝药物维生素K拮抗剂（VKA）、未分离肝素（UFH）和低分子肝素（LMWH）外，新型抗凝药物不断涌现，如戊糖（fondaparinux）和直接凝血酶抑制剂（melagatran／ximelagatran）。

已经不再使用或适应证范围缩小的治疗有：阿司匹林、调整剂量普通肝素、danaparoid、重组水蛭素、右旋糖酐。

新增建议对治疗的方法和治疗的时间疗程更加明确。

对治疗的负面建议更加明确，如：不推荐单独使用阿司匹林用于任何患者群体VTE的预防（证据级别：1A）。

一般建议在患者出院时即应停止使用预防性抗凝治疗，但这些患者中确实有一部分出院后发生无症状性DVT。

ACCP抗栓治疗和血栓预防指南（第九版）介绍之一安徽省立医院ICU 潘爱军美国胸科医师学会在今年第二期《chest》杂志上刊登了抗栓治疗和血栓预防指南（第九版），与上一版指南（2008年发布）相比，新版指南更为简洁明了，新修订的内容以黑体阴影部分标出，首次加入了关于深静脉血栓形成(DVT)的诊断章节。

本期开始将选其要点内容分期摘译登出，以便于大家临床工作中参考。

（为便于与原文对照，要点序号沿用原文指南编号）抗凝治疗的的循证管理2.1 对于能够在门诊接受治疗的患者，推荐维生素拮抗剂（VKA）起始治疗前两天10mg每天一次后根据INR调整剂量；2.2对于启用VKA治疗，不推荐常规采用药物遗传学实验来指导VKA剂量的调整；2.3对于急性深静脉血栓患者，推荐在低分子肝素或普通肝素治疗的第1或第2天起用VKA治疗；3.1对于接受VKA治疗INR监测持续稳定的患者，推荐INR监测频率最长12周而不是每4周一次；3.2对于接受VKA治疗以前INR监测稳定的患者，某单次INR值低于或高于治疗范围的0.5以下，推荐维持目前剂量，1到2周内重新监测INR；3.3对于监测INR稳定的患者，某单次结果低于治疗阈值，不推荐常规联用肝素；3.4对于接受VKA治疗的患者，不推荐常规补充维生素K；3.5（最佳实践说明）推荐管理口服抗凝治疗的医疗保健人员应该采取系统、协作的方式，联合病人的教育、系统的INR监测、跟踪、随访、监测结果和剂量调整同患者有良好的沟通；3.6对于那些接受VKA治疗，活动不受限制且胜任自我管理策略的患者，包括能掌握自我监测的设备，推荐患者自我管理而不必常规门诊随访。

对于其他的患者，推荐包括最佳实践说明（3.5）的安全管理措施；3.7对于VKA治疗维持阶段的剂量调整，推荐使用有效的决策支持工具（decision support tools）如纸质列线图表或计算机辅助剂量表而不是无根据的调整；3.8对于接受VKA治疗的患者，避免同时使用非甾体类抗炎药，包括环氧化酶-2选择性的非甾体类抗炎药和某些抗体；对于接受VKA治疗的患者，避免同时使用抗血小板制剂，除非知晓患者会获益或者益处大于出血风险，如在机械瓣膜患者、急性冠脉综合征患者、新近冠脉支架植入患者和冠脉旁路移植患者；4.1对于接受VKA治疗的患者，推荐INR治疗范围在2.0~3.0之间（目标INR2.5）而不是低于2.0或者高于3.0~4.5；4.2对于以前有过动脉或静脉血栓栓塞症的抗磷脂综合征患者，推荐VKA治疗将INR维持在2.0~3.0而不是3.0~4.5；5.0对于那些适合终止VKA治疗的患者，推荐迅速停用而不是逐渐减量至停用；6.1对于起用静脉普通肝素治疗的患者，推荐在静脉血栓栓塞症的患者肝素的首剂推注量80u/kg然后按照18u/kg.h维持；心脏病或中风患者70u/kg首剂推注后15U/kg.h维持；或者固定剂量首剂5000U然后1000u/h维持；6.2对于门诊接受皮下肝素治疗的静脉血栓栓塞症的患者，推荐按照体重调整剂量：333u/kg首剂，然后250u/kg,无需监测；7.1对于存在严重肾功能不全的患者（计算肌酐清除率＜30ml/min），在接受低分子肝素治疗时，推荐减低剂量而不是标准剂量。