Thrombolysis for acute pulmonary embolism: Are the risks worth the benefits?

The successful application of thrombolytic therapy to the treatment of acute myocardial infarction has stimulated similar attempts to apply thrombolytic therapy to the treatment of acute pulmonary embolism. The development of newer thrombolytic agents and improved protocols for dosing and delivering thrombolytic therapy have provided additional insight into the risks and potential benefits of thrombolysis for acute pulmonary embolism. The purpose of the present review is to examine the risks and benefits of thrombolytic therapy for pulmonary embolism in light of recent investigations.     

血栓栓塞导致急性心肌梗死的临床研究

目的探讨血栓栓塞导致急性心肌梗死的临床特点及预后。方法回顾性分析8例血栓脱落至冠状动脉致急性心肌梗死患者的临床资料,并进行随访。随访内容包括死亡、再次心肌梗死、严重出血、其余部位栓塞事件及国际标准化比值（INR）达标情况。结果患者年龄（63±15）岁。5例为风湿性心脏病换瓣术后患者,1例为肥厚型心肌病患者,2例为扩张型心肌病患者。患者心电图均表现为急性ST段抬高性心肌梗死,其中前壁心肌梗死6例,下壁心肌梗死2例。7例合并心房颤动（87.5%,7/8）。所有患者行急诊冠状动脉造影可见冠状动脉栓塞,其中5例行血栓抽吸术,3例行血栓抽吸及球囊扩张术。院内随访期间,发生大面积脑栓塞死亡1例,国际标准化比值达标率87.5%（6/7）,其余患者未再出现栓塞及严重出血事件。结论血栓栓塞导致心肌梗死发生于血栓形成高危人群,均表现为急性ST段抬高性心肌梗死,急性期使用血栓抽吸术尽早开通冠状动脉,术后予以规范的抗栓治疗,患者预后良好。     

A prospective study on cardiovascular events after acute pulmonary embolism

Aims To evaluate the incidence of cardiovascular events in thelong-term clinical course of patients with a first episode ofsymptomatic, objectively confirmed pulmonary embolism. Methods and results Three hundred and sixty patients with afirst episode of pulmonary embolism were included in a prospectivestudy: 209 with idiopathic pulmonary embolism and 151 with pulmonaryembolism associated with transient risk factors. The study outcomeswere cardiovascular events (recurrent venous thrombo-embolism,acute myocardial infarction, stroke, sudden otherwise unexplaineddeath), cardiovascular death, and death due to any cause. Themedian follow-up was 38 months. Sixty-four patients had at leastone cardiovascular event (5.5% patient-year). Recurrent venousthrombo-embolism occurred in 45 patients (3.9% patient-year),acute myocardial infarction in 12 patients (1.0% patient-year),stroke in six patients (0.5% patient-year), and sudden otherwiseunexplained death in four patients (0.3% patient-year). A cardiovascularevent occurred in 47 patients with idiopathic pulmonary embolism(7.5% patient-year) and in 17 patients with pulmonary embolismassociated with transient risk factors (3.1% patient-year) (RR2.0; 95% CI 1.20–3.34; P=0.006). Twenty patients withidiopathic pulmonary embolism (3.2% patient-year) and two patientswith pulmonary embolism associated with transient risk factors(0.4% patient-year) presented an arterial cardiovascular event(RR 7.2; 95% CI 1.71–30.45; P=0.001). Thirty-three patientsdied (9.2%). Cardiovascular mortality and cancer mortality accountedfor 42.4 and 21.2% of overall mortality, respectively. Idiopathicpulmonary embolism was an independent predictor of cardiovascularevents after adjusting for age. Conclusions Cardiovascular events are more common in patientswith idiopathic pulmonary embolism than in patients with pulmonaryembolism associated with transient risk factors. Cardiovascularevents are the major cause of death in patients with idiopathicpulmonary embolism.     

Pulmonary embolism mimicking acute anterior myocardial infarction: diagnostic trap

Pulmonary embolism remains the major malingerer of acute chest disease. The clinical and electrocardiographic manifestations may deviate to a diagnosis of myocardial infarction. We report a case of bilateral pulmonary embolism in a patient of 50 years. The electrocardiogram showed ST elevation in anteroseptal and lateral leads. The diagnosis of acute myocardial infarction was selected and a fibrinolysis achieved. Getting out under beta-blocker therapy, antiplatelet, statin and angiotensin-converting enzyme inhibitors after 10 days hospitalization, the patient was readmitted one month later for a massive pulmonary embolism. Coronary angiography performed after the second hospitalization was normal.     

硝酸甘油在肺栓塞中的作用

内皮素具有强而持久的血管收缩功能，在肺栓塞急性期含量升高，引起右心房张力增加、肺血管阻力增加和肺动脉血氧饱和度的下降。降钙素基因相关肽是强的血管扩张因子，与内皮素作用相反，两者的平衡失调在急性肺栓塞的血流动力学变化中起着重要作用。脑钠肽反映心室张力，可以预测急性肺栓塞的预后。从目前研究中推论，硝酸甘油可以分别作用于三者，使各血流动力学指标趋于稳定。同时，硝酸甘油对降低肺动脉高压有肯定的作用，还可减少急性肺栓塞溶栓后的缺血再灌注损伤，在急性肺栓塞与急性心肌梗塞不能鉴别时硝酸甘油可用于早期治疗，因此硝酸甘油在肺栓塞中具有重要作用。     

2 cases of acute myocardial infarct complicated by fatal pulmonary embolism

Two cases of pulmonary embolism with lethal course in the setting of acute myocardial infarction are presented. Both cases are clinically characterized by a late pulmonary embolism occurrence (2nd and 3rd week, respectively), and the presence of a large infarct, heart failure during acute myocardial infarction evolution and the interruption of anticoagulant therapy due to a complication. From the anatomic point of view, both cases had large hearts and very large biventricular infarctions. On the other hand, deep venous plexus constituted the pulmonary embolism origin in one case, and right ventricular thrombosis in the other.     

Acute inferior ST-segment elevation myocardial infarction and previous cryptogenic stroke caused by a paradoxical embolism with a concomitant pulmonary embolism

A 61-year-old patient suffered sudden acute ST-segment elevation myocardial infarction (STEMI) after stool, who only took thrombus aspiration by percutaneous coronary intervention (PCI) and got reperfusion totally, without balloon dilatation or stenting. While bilateral pulmonary embolism and deep venous thrombosis (DVT) was found on this patient, warfarin and inferior vena cava filter were used to antithrombotism. From the results of echocardiography, we noticed right ventricular enlargement and pulmonary hypertension, and the retrograde flow was detected at the foramen ovale, which meant patent foramen ovale (PFO), so it was considered that the thrombus caused acute myocardial infarction (AMI) was origianted from DVT through the foramen ovale. This rare case showed the importantce to define the source of the thrombus to find appropriate treatments and effective preventive measures.     

Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction.

BACKGROUND: A normally contracting right ventricular apex associated to a severe hypokinesia of the mid-free wall ('McConnell sign') has been considered a distinct echocardiographic pattern of acute pulmonary embolism. OBJECTIVE: To evaluate the clinical utility of the 'McConnell sign' in the bedside diagnostic work-up of patients presenting to the Emergency Department with an acute right ventricular dysfunction due to pulmonary embolism or right ventricular infarction. DESIGN: Among 201 patients, consecutively selected from our clinical database and diagnosed as having massive or submassive pulmonary embolism or right ventricular infarction, 161 were suitable for an echocardiographic review of regional right ventricular contraction and were included in the study. There were 107 cases with pulmonary embolism (group 1) and 54 cases with right ventricular infarction (group 2). All echocardiographic studies were randomly examined by two experienced and independent echocardiographers, blinded to the patient diagnosis and without Doppler informations. RESULTS: The McConnell sign was detected in 75 of 107 patients in group 1 (70%) and in 36 of 54 patients in group 2 (67%); the finding was absent in 32 cases in group 1 and in 18 cases in group 2 (P=0.657). The sensitivity, specificity, positive and negative predictive values of the McConnell sign for the diagnosis of pulmonary embolism were respectively 70, 33, 67 and 36%. CONCLUSIONS: In a clinical setting of patients with acute right ventricular dysfunction the McConnell sign cannot be considered a specific marker of pulmonary embolism.     

超声心动图诊断急性肺动脉栓塞的价值

目的 :分析评价床旁超声心动图 (ECHO)在急性肺动脉栓塞 (APE)诊断中的实用价值。方法 :采用经胸ECHO对临床怀疑APE的 5 8例患者在 4～ 6h内行床旁ECHO检查。结果 :超声直接检出主肺动脉及左右肺动脉主干近端血栓者 4例 ,均被外科手术或肺动脉造影证实。本组具有典型右心负荷过重超声征象者 15例 (其中包括具有超声直接征象的 4例 ) ,核素肺灌注 通气扫描提示为双肺多发性大面积栓塞。仅右房、右室轻度增大或肺动脉轻度增宽者 19例 ,ECHO无改变者 2 4例 ,但核素肺灌注 通气扫描均提示为肺段或亚段栓塞。结论 :ECHO能够发现主肺动脉、左右肺动脉干内附壁血栓直接提示肺动脉栓塞 ,或根据右室负荷过重表现间接提示肺栓塞的可能 ,但对肺段或亚段栓塞者超声不能作出或排除诊断。     

心电图与D-二聚体在急性肺栓塞患者的诊断价值

目的探讨心电图与D-二聚体在急性肺栓塞患者的诊断价值。方法选择在我院接受诊治的经肺动脉血管造影检查确诊为急性肺栓塞患者58例作为研究对象,另外选取同期在我院治疗的经X线及细菌学检查确诊为慢性支气管炎患者53例作为对照组,所有患者均接受心电图、D-二聚体诊断,探讨心电图、D-二聚体对急性肺栓塞患者诊断价值。结果心电图检测对急性肺栓塞患者检测阳性率为93.10%,显著高于对慢性支气管炎检测阳性率(P0.05);D-二聚体检测对急性肺栓塞患者检测阳性率为89.66%,显著高于对慢性支气管炎检测阳性率(P0.05)。结论心电图与D-二聚体在急性肺栓塞诊断中均具有重要的诊断价值。     

多层螺旋CT和MR肺动脉成像诊断急性肺动脉栓塞的对比研究

目的探究多层螺旋CT肺动脉造影和MR肺动脉成像对急性肺动脉栓塞(PE)疾病的的诊断价值。方法对2014年1月~2015年1月我院临床诊断为急性肺栓塞病接受住院治疗的120例患者进行分组,分组依据为随机数字表法,分为采用多层螺旋CT肺动脉造影诊断的CT组和采用MR肺动脉成像诊断的MR组,每组60例,对两组的诊断价值进行比较。结果两组患者经过检查对PE的显示率均为100%,且两组患者栓子栓塞部位比例相当,无统计学差异(P0.05),PE的间接征象有马赛克征、心包积液、肺动脉高压、胸腔积液、肺段梗死、局限性肺纹理稀疏,两组患者具体征象无统计学差异(P0.05)。结论对急性肺动脉栓塞的患者采用MR肺动脉成像进行诊断较为方便,准确率也高,是一种简便、快捷、无创、有效的诊断方法,值得在临床上推广应用。     

29例急性肺栓塞临床观察及治疗研究

目的分析急性肺栓塞的临床特点,观察溶栓抗凝治疗对急性肺栓塞的临床治疗效果。方法２９例肺栓塞患者根据放射性核素肺灌注通气检查、选择性肺动脉造影或超声心动图确诊。对其中２３例肺栓塞患者行静脉溶栓加抗凝治疗２９例次;６例肝素抗凝治疗,以临床及核素检查评价其治疗效果。结果男性患者中以年轻超力型发病者较高,女性患者以更年期以后发病明显增高。院外误诊率高达７５．９％。临床上以呼吸困难为主要表现者多见;尿激酶或重组组织型纤溶酶原激活剂（ｒｔ－ＰＡ）溶栓２９例次,总有效率为６５．５％。根据本组有限病例观察溶栓效果与栓塞的面积未见差异,而与发病开始到溶栓治疗的时间密切相关（Ｐ＜０．０５）。肝素抗凝６例,１例显效,２例有效,３例无效。结论应提高对急性肺栓塞的警惕性,减少误诊率;尿激酶或ｒｔ－ＰＡ对急性肺栓塞溶栓抗凝治疗安全有效,溶栓时间越早越好;对有溶栓适应证的患者应首选溶栓治疗。     

Streptokinase and heparin versus heparin alone in massive pulmonary embolism: A randomized controlled trial

To test the efficacy of thrombolytic therapy in massive pulmonary embolism, we conducted a prospective randomized controlled trial. Eight patients were randomized to receive either 1,500,000 IU of streptokinase in 1 hour through a peripheral vein followed by heparin or heparin alone. All patients had major risk factors for deep vein thrombosis (DVT) and were considered to have high clinical suspicion for pulmonary embolism (PE). At baseline all patients had a similar degree of systemic arterial hypotension, pulmonary arterial hypertension, and right ventricular dysfunction. The time of onset of cardiogenic shock in both groups was comparable (2.25 ±0.5 hours in the streptokinase group and 1.75 ±0.96 hours in the heparin group). The four patients who were randomized to streptokinase improved in the first hour after treatment, survived, and in 2 years of follow-up are without pulmonary arterial hypertension. All four patients treated with heparin alone died from 1 to 3 hours after arrival at the emergency room (p=0.02). Post-thrombolytic therapy the diagnosis of PE was sustained in the streptokinase group by high probability V/Q lung scans and proven DVT. A necropsy study performed in three patients in the heparin group showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. The results indicate that thrombolytic therapy reduces the mortality rate of massive acute pulmonary embolism.     

急性肺栓塞心电图分析

目的对急性肺栓塞的心电图特征进行总结及分析,旨在提高急性肺栓塞的诊断及治疗水平。方法随机选取我院2008年3月至2013年3月期间所收治的86例急性肺栓塞患者,回顾性分析心电图改变。结果86份心电图中,有79例心电图异常,占据总体的91．8％,有7例心电图正常,占据总体的8．2％。结论在急性肺栓塞的临床诊断过程中,心电图检查及心电图变化特征是非常重要的,具备着不可或缺的作用及价值,医务人员应当提起高度重视,并且在临床诊断中加以应用及推广。     

An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase

A 31-year-old man (175 cm, 82 kg) was referred to the emergency department 2 h after the sudden onset of acute dyspnea. Immediate ECG showed sinus tachycardia with ST elevations from V1 through V2 and a diagnosis of septal acute myocardial infarction was made. ECG on admission to the cardiology department showed the same results plus the S1–Q3–T3 pattern. Echocardiogram revealed a normally contracting left ventricle, a distended right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Thrombolytic therapy with tenecteplase 8000 IU and heparin 5000 IU was administered 5–10 min after hospitalisation and the patient was haemodynamically stable 30 min later. Echocardiogram performed 12 h after thrombolysis showed a normal left ventricle and a less distended right ventricle. Lung spiral computed tomography (CT) and lower abdominal CT on the fourth day showed large emboli in the inferior pulmonary arteries of the right and left lung. Rarely, massive pulmonary embolism may mimic anteroseptal acute myocardial infarction on ECG and this case demonstrates the utility of echocardiography for a differential diagnosis, as well as the efficacy of tenecteplase for thrombolytic therapy.     

急慢性肺栓塞的心脏超声心动图表现

目的:了解急慢性肺栓塞的超声心动图表现。方法:回顾性研究从2001年1月到2006年6月所有肺栓塞的住院患者,共43例,分为急性肺栓塞及慢性肺栓塞,了解其超声心动图的表现(包括右房、右室大小,肺动脉压力,肺动脉主干及分叉处有无血栓回声,左房、左室大小等)。结果:急、慢性肺栓塞病人表现不同程度的肺动脉压力升高,右房、室增大,但慢性组右房、室增大更为明显(P<0.05~<0.01),检出率更高(P<0.05)。结论:急慢性肺栓塞的超声心动图表现有助于提高其检出率。     

急性肺栓塞患者严重程度指数与血清钠水平分析

目的分析急性肺栓塞(APE)患者肺栓塞严重程度指数(PESI)与血清钠水平的病情评估价值和关系。方法回顾性分析经CT肺动脉造影确诊的APE患者临床资料。结果 22例患者入选,PESI低危组均为低危APE,PESI中、高危组的中、高危APE发生率为66.67%,与PESI低危组比较差异显著;共6(27.27%)例APE患者出现低钠血症,其中2(33.33%)例在诊断一月内死亡,低钠血症组和非低钠血症组中、高危APE发生率比较无显著性差异;APE患者血清钠水平与PESI相关系数为-0.318(P=0.149)。结论PESI而非低钠血症对APE病情严重性具有指导价值,合并低钠血症的APE患者一月内死亡率高。     

Pulmonary embolism with acute pancreatitis: a case report and literature review

Acute pancreatitis is an inflammatory disease characterized by local tissue injury which can trigger a systemic inflammatory response. So vascular complications of pancreatitis are a major cause of morbidity and mortality. Pulmonary embolism in acute pancreatitis has been reported to be very rare. We reported a case of pulmonary embolism with acute pancreatitis. A 38-year-old woman broke out upper abdomen pain without definite inducement. She had no nausea and vomiting, fever, dyspnea, cough and expectoration, chest pain. The patient had been diagnosed with acute pancreatitis in local hospital. The patient was treated with antibiotics and proton pump inhibitors, and the abdomen pain was alleviated slightly. But the patient came forth cough and expectoration with a little blood, progressive dyspnea. A computed tomographic scan of the abdomen revealed pancreatitis. Subsequent computer tomography angiography of chest revealed pulmonary embolism (both down pulmonary arteries, left pulmonary artery and branch of right pulmonary artery). Dyspnea of the patient got well with thrombolytic treatment and anticoagulation therapy. Pulmonary embolism is a rare but potentially lethal complication of pancreatitis. Familiarity with this complication will aid in its early diagnosis, therapy and prevent pulmonary embolism, a rare but catastrophic phenomenon.     

急性肺栓塞的诊治进展

急性肺栓塞（pulmonary embolism，PE）是各种内源性或外源性栓子堵塞肺动脉，引起的肺循环障碍的临床和病理生理综合征，是一种常见的心肺疾患，其发病率、病死率、误诊率高，近年来日益受到人们的重视。正确诊断和及时治疗是降低PE患者病死率的关键。为了提高对急性肺栓塞的认识水平，现就其诊断及治疗进展作一综述。     

急性心肌梗死合并双下肢动脉栓塞1例伴遗传易感性分析

目的:探讨1例急性心肌梗死合并双下肢动脉栓塞的临床特征,并分析其遗传易感性。方法:分析1例急性心肌梗死合并双下肢动脉栓塞患者的临床表现,并采用PCR-直接测序法探究其血栓遗传倾向。结果:该患者为75岁男性,临床表现和影像学诊断均支持急性心肌梗死后并发的双下肢动脉栓塞,经溶栓、抗凝、抗血小板聚集、稳定斑块等治疗后病情好转。遗传易感性分析发现,该患者存在高同型半胱氨酸血症和亚甲基四氢叶酸还原酶(MTHFR)基因C677T杂合性点突变,但未发现活化蛋白C(APC)抵抗、凝血因子Ⅴ(FⅤ)基因Leiden突变及凝血酶原(FⅡ)基因G20210A突变。结论:动脉栓塞性疾病不仅与获得性病因有关,还与遗传因素有关,易感基因筛查有助于判断血栓栓塞遗传倾向。