奥氮平使用合并静脉血栓栓塞症16例临床分析

doi:10.3969/j.issn.1004-583X.2022.12.008

摘要/Abstract

摘要：

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。

关键词: 静脉血栓栓塞, 肺栓塞, 抗精神病药物, 奥氮平, 精神疾病

Abstract:

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.

Key words: venous thromboembolism, pulmonary thromboembolism, antipsychotic drugs, olanzapine, mental illness

中图分类号:

R619.2

王娇燕, 章迎春, 任珂明, 马国峰, 应可净. 奥氮平使用合并静脉血栓栓塞症16例临床分析[J]. 临床荟萃, 2022, 37(12): 1108-1113.

Wang Jiaoyan, Zhang Yingchun, Ren Keming, Ma Guofeng, Ying Kejing. Clinical analysis of 16 cases of venous thromboembolism combined with psychiatric disorders treated with olanzapine[J]. Clinical Focus, 2022, 37(12): 1108-1113.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2022.12.008

https://huicui.hebmu.edu.cn/CN/Y2022/V37/I12/1108

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参考文献 40

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序号	性别	年龄 (岁)	精神疾病	约束具	VTE	D-二聚体 (μg/ml)	心脏超声	心电图	VTE距首次抗精神病药物使用时间	精神疾病用药及使用剂量
1	男	57	阿尔茨海默病	无	肺栓塞(低危)	5.09	阴性	阴性	6月内	奥氮平2.5 mg/d, 多奈哌齐10 mg/d
2	女	44	抑郁障碍	有	肺栓塞(高危)	5.05	阴性	阴性	1年内	奥氮平2.5 mg/d, 米氮平10 mg/d
3	女	65	中度抑郁发作	无	肺栓塞(低危)	2.36	阴性	阴性	5年内	奥氮平5 mg/d, 艾司西酞普兰20 mg/d
4	女	61	路易体痴呆	无	肺栓塞(低危)	0.77	阴性	阴性	6月内	奥氮平2.5 mg/d, 多奈哌齐5 mg/d, 氟伏沙明150 mg/d
5	男	82	复发性抑郁障碍	无	肺栓塞(低危)	1.66	阴性	阴性	5年内	奥氮平2.5 mg/d, 度洛西汀120 mg/d
6	男	72	复发性抑郁障碍	无	肺栓塞(低危)	0.68	阴性	阴性	6月内	奥氮平2.5 mg/d, 度洛西汀120 mg/d
7	男	69	轻度抑郁发作	无	肺栓塞(低危)	7.7	阴性	阴性	6月内	奥氮平2.5 mg/d, 艾司西酞普兰20 mg/d
8	女	72	器质性情绪障碍	无	肺栓塞(低危)	2.23	阴性	阴性	6月内	奥氮平2.5 mg/d, 氟西汀20 mg/d
9	女	65	轻度认知障碍	无	左下肢静脉血栓	0.96	阴性	阴性	1年内	奥氮平2.5 mg/d
10	女	63	重度抑郁发作	无	肺栓塞(低危)	1.55	阴性	阴性	5年内	奥氮平2.5 mg/d, 文拉法辛225 mg/d
11	男	75	抑郁状态	无	左下肢静脉血栓	1.02	阴性	阴性	6月内	奥氮平2.5 mg/d, 舍曲林150 mg/d
12	男	69	焦虑障碍	无	肺栓塞(低危)、双下肢静脉血栓	18.1	阴性	阴性	6月内	奥氮平2.5 mg/d, 喹硫平25 mg/d
13	女	69	抑郁发作	无	肺栓塞(低危)	2.67	阴性	阴性	6月内	奥氮平2.5 mg/d, 艾司西酞普兰15 mg/d
14	女	69	抑郁发作	无	肺栓塞(低危)	1.11	阴性	阴性	1年内	度洛西汀60 mg/d, 奥氮平5 mg/d
15	女	73	混合性焦虑和抑郁障碍	无	双下肢静脉血栓	1.54	阴性	阴性	6月内	奥氮平2.5 mg/d, 黛力新10 mg/d
16	女	67	抑郁发作	无	肺栓塞(低危)	2.13	阴性	阴性	6月内	度洛西汀60 mg/d, 奥氮平2.5 mg/d

序号	性别	年龄 (岁)	精神疾病	约束具	VTE	D-二聚体 (μg/ml)	心脏超声	心电图	VTE距首次抗精神病药物使用时间	精神疾病用药及使用剂量
1	男	57	阿尔茨海默病	无	肺栓塞(低危)	5.09	阴性	阴性	6月内	奥氮平2.5 mg/d, 多奈哌齐10 mg/d
2	女	44	抑郁障碍	有	肺栓塞(高危)	5.05	阴性	阴性	1年内	奥氮平2.5 mg/d, 米氮平10 mg/d
3	女	65	中度抑郁发作	无	肺栓塞(低危)	2.36	阴性	阴性	5年内	奥氮平5 mg/d, 艾司西酞普兰20 mg/d
4	女	61	路易体痴呆	无	肺栓塞(低危)	0.77	阴性	阴性	6月内	奥氮平2.5 mg/d, 多奈哌齐5 mg/d, 氟伏沙明150 mg/d
5	男	82	复发性抑郁障碍	无	肺栓塞(低危)	1.66	阴性	阴性	5年内	奥氮平2.5 mg/d, 度洛西汀120 mg/d
6	男	72	复发性抑郁障碍	无	肺栓塞(低危)	0.68	阴性	阴性	6月内	奥氮平2.5 mg/d, 度洛西汀120 mg/d
7	男	69	轻度抑郁发作	无	肺栓塞(低危)	7.7	阴性	阴性	6月内	奥氮平2.5 mg/d, 艾司西酞普兰20 mg/d
8	女	72	器质性情绪障碍	无	肺栓塞(低危)	2.23	阴性	阴性	6月内	奥氮平2.5 mg/d, 氟西汀20 mg/d
9	女	65	轻度认知障碍	无	左下肢静脉血栓	0.96	阴性	阴性	1年内	奥氮平2.5 mg/d
10	女	63	重度抑郁发作	无	肺栓塞(低危)	1.55	阴性	阴性	5年内	奥氮平2.5 mg/d, 文拉法辛225 mg/d
11	男	75	抑郁状态	无	左下肢静脉血栓	1.02	阴性	阴性	6月内	奥氮平2.5 mg/d, 舍曲林150 mg/d
12	男	69	焦虑障碍	无	肺栓塞(低危)、双下肢静脉血栓	18.1	阴性	阴性	6月内	奥氮平2.5 mg/d, 喹硫平25 mg/d
13	女	69	抑郁发作	无	肺栓塞(低危)	2.67	阴性	阴性	6月内	奥氮平2.5 mg/d, 艾司西酞普兰15 mg/d
14	女	69	抑郁发作	无	肺栓塞(低危)	1.11	阴性	阴性	1年内	度洛西汀60 mg/d, 奥氮平5 mg/d
15	女	73	混合性焦虑和抑郁障碍	无	双下肢静脉血栓	1.54	阴性	阴性	6月内	奥氮平2.5 mg/d, 黛力新10 mg/d
16	女	67	抑郁发作	无	肺栓塞(低危)	2.13	阴性	阴性	6月内	度洛西汀60 mg/d, 奥氮平2.5 mg/d

项目	例数(%)
无胸闷气急、呼吸困难、下肢肿胀等主诉	14(87.50)
一过性的胸闷气急、呼吸困难	2(12.50)
D-二聚体升高	16(100.00)
高脂血症	9(56.25)
高同型半胱氨酸血症	8(50.00)
高催乳素血症	5(31.25)
凝血因子Ⅷ升高	2(12.50)
凝血因子Ⅸ升高	1(6.25)
蛋白S低	1(6.25)

项目	例数(%)
无胸闷气急、呼吸困难、下肢肿胀等主诉	14(87.50)
一过性的胸闷气急、呼吸困难	2(12.50)
D-二聚体升高	16(100.00)
高脂血症	9(56.25)
高同型半胱氨酸血症	8(50.00)
高催乳素血症	5(31.25)
凝血因子Ⅷ升高	2(12.50)
凝血因子Ⅸ升高	1(6.25)
蛋白S低	1(6.25)

序号	下肢静脉彩色超声	CTPA	治疗后复查
1	阴性	左肺下叶后基底段分支内、左肺上叶下舌段管腔内可疑少许肺栓塞	左肺下叶后基底段分支内管腔内少许可疑肺栓塞
2	阴性	双肺上下叶及部分肺段动脉分支内充盈缺损,考虑肺栓塞	左肺动脉部分叶段动脉可疑充盈缺损,较前片明显好转
3	阴性	右肺下叶外基底段肺动脉栓塞	两肺动脉未见明显栓塞征象,对比前片栓塞此次未见
4	阴性	右下肺后基底段肺动脉分支栓塞	两肺动脉未见明显栓塞征象
5	阴性	右肺动脉主干、右肺各叶段及左肺舌段肺动脉栓塞	未复查
6	阴性	右肺中叶及两肺下叶部分动脉其分支内见条片状充盈缺损,考虑肺栓塞	未复查
7	阴性	右肺上、中、下叶动脉、左肺下叶部分亚段分支内见少量充盈缺损影	左肺下叶后基底段动脉可疑充盈缺损
8	阴性	右肺中动支、左肺上动脉分支、两脉分肺下动脉及其分支内见充盈缺损影	未复查
9	左下肢肌间静脉血栓形成	CTPA阴性	下肢静脉彩色超声阴性
10	阴性	双肺叶及部分段动脉内充盈缺损,考虑肺栓塞	两肺动脉未见明显充盈缺损
11	左下肢肌间静脉血栓形成	CTPA阴性	下肢静脉彩色超声阴性
12	双下肢肌间静脉血栓形成	左肺各叶及右肺中下叶肺动脉内充盈缺损,考虑肺栓塞	两肺动脉未见明显栓塞征象右下肢可见肌间静脉血栓
13	阴性	右肺动脉及左下肺动脉部分分支栓塞	两肺动脉未见栓塞征象
14	阴性	右上肺前段肺动脉内小充盈缺损,肺栓塞考虑	两肺动脉未见明显栓塞征象
15	双下肢肌间静脉血栓形成	CTPA阴性	双下肢静脉彩色超声阴性
16	阴性	右肺动脉部分分支栓塞	两肺动脉未见明显栓塞征象