对于急性 PE 后（及 3 个月的抗凝治疗后）出现持续性呼吸困难的患者，应排除其患慢性血栓栓塞性肺动脉高压 (CTEPH) 的可能性。[75]Konstantinides SV, Torbicki A, Agnelli G, et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov 14;35(43):3033-69.https://academic.oup.com/eurheartj/article/35/43/3033/503581http://www.ncbi.nlm.nih.gov/pubmed/25173341?tool=bestpractice.com 不推荐常规进行 CTEPH 的筛查。建议诊断为 CTEPH 的患者进行长期抗凝治疗。[75]Konstantinides SV, Torbicki A, Agnelli G, et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov 14;35(43):3033-69.https://academic.oup.com/eurheartj/article/35/43/3033/503581http://www.ncbi.nlm.nih.gov/pubmed/25173341?tool=bestpractice.com
在静脉血栓栓塞的管理中，没有单一的可明确监测胃肠外肝素使用的手段。一个建议的方法为每 6 小时检测一次活化部分凝血活酶时间 (aPTT) 或抗凝血因子 Xa 抗体，直到获得两次连续的疗效结果，此后的检测频率即可降至每日一次。[196]Smythe MA, Priziola J, Dobesh PP, et al. Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism. J Thromb Thrombolysis. 2016 Jan;41(1):165-86.https://link.springer.com/article/10.1007%2Fs11239-015-1315-2http://www.ncbi.nlm.nih.gov/pubmed/26780745?tool=bestpractice.com对于存在肝素抵抗、基线 aPTT 延长、或肝素治疗反应改变的患者，监测抗凝血因子 Xa 抗体水平可能优于 aPTT。[196]Smythe MA, Priziola J, Dobesh PP, et al. Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism. J Thromb Thrombolysis. 2016 Jan;41(1):165-86.https://link.springer.com/article/10.1007%2Fs11239-015-1315-2http://www.ncbi.nlm.nih.gov/pubmed/26780745?tool=bestpractice.com当监测抗 Xa 因子时，建议的有效血药浓度范围为 0.3-0.7 单位/mL。[196]Smythe MA, Priziola J, Dobesh PP, et al. Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism. J Thromb Thrombolysis. 2016 Jan;41(1):165-86.https://link.springer.com/article/10.1007%2Fs11239-015-1315-2http://www.ncbi.nlm.nih.gov/pubmed/26780745?tool=bestpractice.com
进行维生素 K 拮抗剂治疗的患者需频繁监测国际标准化比值 (INR)，最好是在抗凝专科门诊进行。不过，特定患者可使用便携式即时检测单元进行维生素 K 拮抗剂治疗的自我监测。若接受口服抗凝剂治疗的患者进行自我监测或自我管理，则可改善其口服抗凝治疗的质量。[197]Heneghan CJ, Garcia-Alamino JM, Spencer EA, et al. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev. 2016 Jul 5;(7):CD003839.http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003839.pub3/fullhttp://www.ncbi.nlm.nih.gov/pubmed/27378324?tool=bestpractice.com
达比加群、利伐沙班、阿哌沙班和依度沙班的治疗无需使用凝血检测进行实验室监测。在开始直接口服抗凝剂治疗前评估肾功能以及在治疗过程中进行肝肾功能监测应按照临床需要进行。
共识指南推荐，对于接受低分子肝素治疗的患者，应对其出血症状和体征以及对需调整剂量的肾功能改变进行监测。[196]Smythe MA, Priziola J, Dobesh PP, et al. Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism. J Thromb Thrombolysis. 2016 Jan;41(1):165-86.https://link.springer.com/article/10.1007%2Fs11239-015-1315-2http://www.ncbi.nlm.nih.gov/pubmed/26780745?tool=bestpractice.com应定期监测全血细胞计数、血小板计数和血清肌酐；不推荐对抗凝血因子 Xa 抗体进行常规监测。[196]Smythe MA, Priziola J, Dobesh PP, et al. Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism. J Thromb Thrombolysis. 2016 Jan;41(1):165-86.https://link.springer.com/article/10.1007%2Fs11239-015-1315-2http://www.ncbi.nlm.nih.gov/pubmed/26780745?tool=bestpractice.com
大多数患者可能无需对磺达肝癸钠进行常规的治疗监测；若怀疑磺达肝癸钠蓄积，可考虑进行为磺达肝癸钠进行调整的抗 Xa 因子试验。[196]Smythe MA, Priziola J, Dobesh PP, et al. Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism. J Thromb Thrombolysis. 2016 Jan;41(1):165-86.https://link.springer.com/article/10.1007%2Fs11239-015-1315-2http://www.ncbi.nlm.nih.gov/pubmed/26780745?tool=bestpractice.com
