奥氮平使用合并静脉血栓栓塞症16例临床分析

Clinical analysis of 16 cases of venous thromboembolism combined with psychiatric disorders treated with olanzapine

目的提高对精神疾病患者静脉血栓栓塞症(venous thromboembolism,VTE)的早期识别、早期诊断水平。方法纳入2019年5月-2022年3月首诊于浙江大学医学院附属邵逸夫医院精神卫生科的精神疾病合并VTE的患者16例,收集这些患者的临床症状、实验室及影像学检查、抗精神疾病用药情况及治疗预后等。结果16例患者中,男性6例,女性10例,平均年龄67岁,其中13例诊断为肺栓塞,4例为下肢静脉血栓,其中1例患者表现为肺栓塞合并下肢静脉血栓。肺栓塞和下肢静脉血栓的确诊遵循中国血栓性疾病防治指南2018版。12例肺栓塞为低危,1例为高危。有2例患者发病前有一过性的胸闷气急、呼吸费力,余14例患者无明显的胸闷气急、呼吸费力等症状。16例患者D-二聚体均异常,9例患者存在高脂血症,8例存在高同型半胱氨酸血症,5例存在高催乳素血症,2例存在凝血因子Ⅷ升高。10例患者的VTE发生在使用抗精神病药物的前6个月内,3例发生在1年内,3例发生在5年内。16例患者均使用了奥氮平。使用Caprini和Padua血栓风险评估量表评估,16例患者血栓风险均为低度。结论精神疾病患者发生VTE事件时临床表现不典型,常无明显的临床症状,容易漏诊漏治,且不适用于常规的VTE预防评估量表。精神疾病患者的VTE事件多发生在使用奥氮平的前6个月内,常伴有D-二聚体的异常升高和其他代谢性实验室指标的异常,精神疾病患者同时服用奥氮平或可诱发VTE,需要临床高度关注。

Objective To improve the early recognition and early diagnosis of venous thromboembolism(VTE) in patients with psychiatric disorders.Methods Clinical symptoms, laboratory and imaging tests, anti-psychotic medication and treatment prognosis of 16 patients with psychiatric disorders combined with VTE who were first diagnosed in the Department of Mental Health, Sir Run Run Shaw Hospital affiliated to Zhejiang University from May 2019 to March 2022 were retrospectively analyzed.Results Among the 16 patients, there were 6 males and 10 females with an average age of 67 years. 13/16 were diagnosed with pulmonary embolism, 4/16 were diagnosed as deep venous thrombosis, and 1 suffered pulmonary embolism complicated with deep venous thrombosis. The diagnosis of pulmonary embolism and deep venous thrombosis was confirmed following the Chinese guidelines for the prevention and treatment of thrombotic diseases 2018 edition. 12 cases of pulmonary embolism were low-risk and one case was high-risk. Two patients had transient chest tightness and shortness of breath before onset, while the remaining 14 patients had no obvious symptoms of chest tightness and shortness of breath. 16 patients had abnormal D-dimer, 9 had hyperlipidemia, 8 had hyperhomocysteinemia, 5 had hyperprolactinemia and 2 had elevated coagulation factor Ⅷ. 10 patients had VTE within the first 6 months of antipsychotic use. 3 cases occurred within 1 year and 3 cases occurred within 5 years. Olanzapine was given to all 16 patients. The risk of thrombosis was low in all 16 patients, as assessed by the Caprini and Padua Thrombosis Risk Assessment Scale.Conclusion The clinical presentation of VTE in patients with psychiatric disorders is atypical that lacks obvious clinical signs and symptoms, easily leading to misdiagnosed and untimely treatment. Conventional VTE prevention assessment scales are not suitable for them. VTE in patients with psychiatric disorders most often occurs within the first 6 months of olanzapine use, which is often associated with abnormal elevations in D-dimer and other metabolic laboratory markers. Concurrent olanzapine use in patients with psychiatric disorders may precipitate VTE and requires significant clinical attention.