以血流动力学及影像学分型的大面积肺栓塞患者临床特征比较

目的 比较影像学与血流动力学分型的大面积肺栓塞(MPE)的临床特点,加强临床医生对血流动力学MPE的认识.方法 资料来源于国家"十五"科技攻关课题的大规模肺栓塞临床研究数据库,研究纳入了229例溶栓治疗患者,其中男139例,女90例,平均年龄(55±15)岁.其中53例符合血流动力学MPE标准(A组),176例符合影像学MPE标准(B组).血流动力学MPE的诊断标准为临床上以休克和低血压为主要表现,即体循环收缩压＜90 mm Hg(1 nnn Hg=0.133 kPa),或较基础值下降幅度≥40 mm Hg,持续15 min以上,并除外新发生的心律失常、低血容量或感染中毒症等其他原因所致的血压下降;影像学MPE的诊断标准为影像学提示栓塞部位≥2个肺叶或≥7个肺段.结果 两组基线资料相同,呼吸困难(＞90%)、呼吸频率增快及第2心音亢进为常见临床表现,两组间差异无统计学意义(P＞0.05).CT肺动脉造影中央肺动脉受累、血管阻塞比例＞50%、肺动脉阻塞指数及心脏超声血栓直接征象发生率两组差异无统计学意义(P＞0.05).A组心悸、晕厥、惊恐、濒夕匕感、发绀、心动过速及颈静脉允盈的发生率均高于B组;除右心室壁运动幅度和下腔静脉深吸气最小直径外,A组多项反映右心负荷增加的心脏超声指标均重于B组,2组比较差异有统计学意义(P＜0.01＞.结论 尽管从解剖学角度两组的血流阻塞程度一致,但血流动力学障碍程度明显不同,提示影像学MPE不完全等同于血流动力学MPE,临床工作中对急性肺栓塞进行危险性评估时应了解两者的差异.

A comparison of clinical characteristics between radiological and hemodynamic massive pulmonary embolism

Objective To investigate the similarities and differences of massive pulmonary embolism (MPE) diagnosed by hemodynamic or radiological criteria,and therefore to improve physician' s awareness of MPE from different aspects.Methods The data were collected from a prospective,multi center study for pulmonary thromboembolism.Fifty-three cases of MPE diagnosed by hemodynamic criteria were enrolled into group A,which was defined as shock and/or hypotension[systemic arterial pressure ＜ 90 mm Hg (1 mm Hg =0.133 kPa) or a pressure drop≥40 mm Hg]for ＞ 15 min without new-onset arrhythmia,hypovolemia,or sepsis.MPE based on radiological criteria were enrolled into group B (n = 176),which was defined as pulmonary artery obstruction with more than 2 lobes or 7 segments.Results The baseline data of the 2 groups showed no difference.Common clinical manifestations included dyspnea,increase of respiratory rate,and accentuation of P2,no significant differences between the 2 groups.There were no differences in central pulmonary artery emboli,more than 50% pulmonary artery obstruction and pulmonary artery obstruction index by CTPA,and indirect signs of emboli by doppler echocardiography as well(P＞0.05).However,the incidences of palpitation,syncope,horror-struck,tachycardia,cyanosis and elevated neck veins were higher in group A than those in group B (P ＜ 0.05).Excluding right ventricular wall motion and inspiratory diameter of inferior vena cava,other indexes associated with right ventricular dysfunction revealed by the echocardiography were worse in group A than in group B(P ＜ 0.01).Conclusions Although the degree of vascular obstruction was consistent in the anatomical aspects between the 2 groups,the hemodynamic disorder was significantly different,suggesting that MPE based on radiological criteria was not exactly the same as hemodynamic MPE.Clinicians should be aware of these differences when assessing the severity of acute pulmonary embolism.