肺栓塞诊治体会 (附9例报告)

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：9例肺栓塞患根据临床症状，体格检查、同位素肺灌注扫描或超声心动图检查确诊。对其中3例行静脉溶栓加抗凝治疗，6例行肝素抗凝治疗，以临床及超声心动图或胸部X线片评价治疗效果。结果：溶栓组3例均痊愈，抗凝组3例有效，3例死亡。结论：应提高对肺栓塞的警惕性，减少误诊率；尿激酶溶栓治疗优于肝素抗凝治疗，溶栓时间越早越好；对有溶栓适应症应首选溶栓治疗。     

58例急性肺栓塞治疗方案的选择与评估

目的 探讨急性肺栓塞（ＡＰＥ）的最佳治疗方案。评估重组组织型纤溶酶原激活剂和尿激酶（ＵＫ）２小时连续静脉溶栓法的可行性及临床疗效。方法 ５８例经放射性核素肺灌注通过扫描（ＥＣＴ）或选择性肺动脉造影（ＣＰＡ）确诊为ＡＰＥ的患者,采用ｒｔ－ＰＡ或ＵＫ２小时连续静脉滴注法（简称２小时法）或ＵＫ小剂量每日１次３￣７日法溶栓及单纯抗凝法,栓子切除法治疗。比较并分析不同治疗方案的临床疗效。结果 溶栓治疗４１例     

肺栓塞的介入性治疗和并发症的预防

１　肺栓塞（ＰＥ）介入治疗的适应证１－１　ＰＥ介入溶栓适应证　ＰＥ血流动力学不稳定者是溶栓或介入溶栓的适应证,应用尿激酶或链激酶、重组组织纤维蛋白溶酶原激活剂（ｒｔ－ＰＡ）使肺栓子、深静脉血栓溶解,以改善血流动力障碍造成的严重病情和消除再次栓塞肺动脉栓子的来源。血流动力学稳定者是抗凝治疗适应证,可先给肝素,目前常选用ＬＭＷＨ［１］。１－２　安装下腔静脉滤过器的适应证　为防止下肢、盆腔静脉脱落栓子使ＰＥ重复发生,尤其有活动性出血不能用抗凝治疗以消除血栓的病人,或抗凝失败仍反复发生ＰＥ的病人,应安装…     

不同溶栓药物静脉溶栓治疗急性心肌梗塞的比较观察

对９０例发病１２小时以内的ＡＭＩ患者，分别给予ＵＫ、ＳＫ、ｒｔ－ＰＡ进行溶栓治疗，并辅以肝素、阿司匹林治疗。结果表明，ＵＫ组、ＳＫ组及ｒｔ－ＰＡ组的临床血管再通率分别为６７．５％、７３．３％、８５％。并发重度出血率ｒｔ－ＰＡ组为１５％，而另两组为０。     

重组组织型纤溶酶原激活剂静脉溶栓治疗急性心肌？…

目的：观察重组组织型纤溶酶原激活剂（ｒｔ－ＰＡ）静脉溶栓治疗急性心肌梗死（ＡＭＩ）的疗效和安全性。方法：选择１４例ＡＭＩ患者应用ｒｔ－ＰＡ静脉溶栓治疗。观察临床太，心电图、心肌酶谱的变化，判断冠状动脉再经。结果；根据冠脉再通标准判断，１４例ＡＭＩ患者，冠脉再通１０例，再通率７１．４３％，其中１０例发病６ｈ以内栓再通８例，再通率８０％，４例发病６～２４ｈ溶栓再通２例，再通率５０％，两者相比有显著差异     

31例肺栓塞误诊原因及不同治疗方法效果的分析

目的 :分析肺栓塞诊断方法及误诊、误治后果 ,观察肺栓塞溶栓和 或抗凝疗法的治疗效果。方法 :据首发症状、初步诊断、辅助检查等分析误诊原因 ,31例肺栓塞分别采用尿激酶溶栓、肝素抗凝治疗及对症治疗。结果 :9例用尿激酶溶栓 +抗凝治疗者治愈 2例 ,显效 2例 ,好转 4例 ,无效 1例 ,总有效率 88 9% ;8例单纯抗凝治疗者治愈 1例 ,显效 1例 ,好转 4例 ,无效 2例 ,总有效率 75 % ;对症治疗组 14例 ,仅好转 3例 ,无效 11例 ,总有效率为 2 1 4%。溶栓及抗凝治疗中未见严重出血及其他副作用。结论 :急性肺栓塞患者早期使用尿激酶进行溶栓治疗可取得较好的临床疗效。延误诊断与病死率呈正相关。早期诊断正确治疗可以减少病死率。     

急性心肌梗死溶栓患者凝血与纤溶系统的改变及临床意义

目的应用链激酶（ＳＫ）、重组链激酶（ｒ－ＳＫ）、尿激酶（ＵＫ）、重组组织型纤溶酶原激活物（ｒｔ－ＰＡ）溶栓治疗急性心肌梗死（ＡＭＩ）患者,比较其凝血与纤溶系统的动态变化。方法对４３例经溶栓治疗（ＳＫ８例,ｒ－ＳＫ１３例,ＵＫ１６例,ｒｔ－ＰＡ６例）的ＡＭＩ患者,分别于溶栓前后动态检测凝血酶原时间（ＰＴ）、活化的部分凝血活酶时间（ＡＰＴＴ）、纤维蛋白原（ＦＧ）、Ｄ二聚体（Ｄ－Ｄｉｍｅｒ）、纤溶酶原（ＰＬＧ）、α２抗纤溶酶（α２ＡＰ）、组织型纤溶酶原激活物（ｔ－ＰＡ）、组织型纤溶酶原激活物抑制物（ＰＡＩ－１）等指标的活性或含量。结果应用ＳＫ、ｒ－ＳＫ、ＵＫ、ｒｔ－ＰＡ溶栓治疗后,均会引起凝血活性的明显降低与纤溶活性的明显增高。ＳＫ与ｒ－ＳＫ对凝血与纤溶系统的影响略高于ＵＫ。ｒｔ－ＰＡ对ＦＧ含量影响低于另外３者（Ｐ值均＜００５）。结论凝血与纤溶活性的变化与溶栓疗效关系密切     

肺动脉栓塞20例诊治分析

目的 探讨急性肺栓塞和诊断、抗凝治疗的安全性和时间窗.方法 对2005-2007 年确诊的20例急性肺栓塞的患者临床表现、鉴别诊断及治疗进行临床分析.结果 20例肺栓塞的首次误诊率为75%,血气分析有低氧血症者占95%,D-二聚体阳性占90%,超声心动呈典型改变占90%.溶栓5例,4例有效.肝素抗凝14例,13例有效.结论 应提高对急性肺栓塞的警惕性,减少误诊率.抗凝治疗安全有效,溶栓治疗越早越好.     

肺栓塞18例临床分析

目的分析急性肺栓塞的临床特点,提高肺栓塞的诊治水平.方法回顾性分析18例肺栓塞患者的临床特点和治疗.结果院外误诊率72.2%.临床表现多样,血气分析、X线胸片、心电图对诊断有帮助.确诊需靠肺灌注通气检查、选择性肺动脉造影及超声心动图检查.治疗有尿激酶溶栓及肝素抗凝.结论应提高对肺栓塞的警惕性,早期诊断、早期治疗是改善预后的关键.     

溶栓加序贯抗凝治疗次大面积肺栓塞疗效观察

目的探讨溶栓加序贯抗凝治疗方案在次大面积肺栓塞治疗的有效性和安全性。方法选择次大面积肺栓塞患者70例,随机分为对照组与观察组各35例,对照组患者给予低分子肝素及华法林抗凝治疗,观察组患者给予尿激酶溶栓同时行低分子肝素及华法林抗凝治疗,比较两组的治疗效果。结果治疗后两组患者PaO2、PaCO2、PA-aO2较治疗前均有显著改善（P〈0．05或0．01）,观察组效果优于对照组（P〈0．01）;心率及呼吸频率较治疗前均显著降低（P〈0．05或0．01）,且观察组显著低于对照组（P〈0．05或0．01）。CT肺动脉造影检查结果显示,观察组总有效率高于对照组（P〈0．05）,且观察组出血倾向无显著增加。结论尿激酶溶栓同时行低分子肝素及华法林抗凝治疗次大面积肺栓塞疗效确切,安全可靠。     

急性肺血栓栓塞症溶栓及抗凝治疗多中心临床分析

目的 分析急性肺血栓栓塞症（PTE）患者的临床资料并观察溶栓和抗凝治疗的疗效。方法 收集患得的病史,浆确诊的127例急性PTE患者分为3组,A组患者予以尿激酶2万U/kg溶于生理盐水100ml中,静脉滴注,2h滴完,溶栓结束后,每4h检测一次激活的部分凝血活酶时间或激活的全血凝固时间,待其恢复至基础值的1.5-2.0倍以内,开始予以皮下注射低分子量肝素0.4ml,每12h一次,共7d,并重叠口服华法林4-5d,尔后单纯应用华法林,初使剂量为3mg,再根据国际标准化比率调整华法林剂量,直至INR达到2-3,B组患者只用尿激酶静脉溶栓而不同低分子量肝素抗凝,并口服华法林,尿激酶及华法林的用法同A组,C组患者予以皮下注射低分子量肝素0.4ml,每12h一次,共7d,并重叠口服华法林,华法林的用法同A组,治疗前后以临床表现及核素肺灌注显像或CT或肺动脉造影检查进行对比分析。观察其疗效,结果 127例患者最常见的易患因素是深静脉血栓形成,临床症状以呼吸困难最为常见,其次是咳嗽,胸痛、咯血和晕厥。70例用尿激酶溶栓和低分子量肝素抗凝治疗者,有效率为90.0%,有2例患者发生轻度出血;31例单用尿激酶溶栓者,有效率为77.4%,有1例患者发生轻度出血;26例单用低分子量肝素抗凝治疗者,有效率为61.5%,有1例患者发生轻度出血,尿激酶溶栓总有效率为86.1%,症状出现后1周内进行溶栓效果最好（92.7%),2周以上也有一定疗效（81.8%)。结论 联合应用尿激酶溶栓和低分子量肝素抗凝治疗急性PTE安全、有效。     

Thrombi of the right heart. Value of thrombolytic therapy in mobile thrombi]

Seven patients with mobile right heart thrombi, 4 floating and 3 pediculated, were recensed between 1985 and 1990. Two patients were admitted for congestive cardiac failure (Group I) and 5 patients for pulmonary embolism (Group II). Both patients in Group I were treated with heparin without complications. In one case, the size of the thrombus decreased in 10 days whereas, in the second case, it disappeared within 8 days. In Group II, the first patient underwent successful thrombectomy. The other four patients were given thrombolytic therapy (UK = 2, rt-PA = 2) associated with appropriate doses of heparin. In the two patients given UK (3M units the first day followed by 1.2 M units per day for 4 days) the thrombus disappeared in the first 48 hours of treatment. One patient had a recurrent pulmonary embolism after 2 hours' treatment; both patients had a fall in haemoglobin of 3 cg/ml at the second day. The second patient died at the 5th day. In the two patients treated by rt-PA (100 mg/7 hours) the thrombus disappeared within 4 hours of starting therapy. One patient had a probable recurrent pulmonary embolism. Both patients had a fall in haemoglobin of 3 cg/ml at the 2nd day of treatment. Right heart thrombi are rare (168 cases in the literature of which 111 were mobile). The prognosis seems to be related to echocardiographic appearances: mortality of mural thrombi is about 4% compared with 50% in mobile thrombi. Very mobile "worm-like" masses are therapeutic emergencies because of the risk of embolism (about 68%).(ABSTRACT TRUNCATED AT 250 WORDS)     

急性肺栓塞二次溶栓治疗的疗效及安全性评价

目的 评价急性肺栓塞二次溶栓治疗的疗效及安全性.方法 回顾分析2002年7月～2010年10月在我院住院的12例需溶栓的急性肺栓塞病人,予重组组织型纤溶酶原激活剂(rt-PA)50 mg静脉输注,24小时后复查CT肺动脉造影(CTPA)、心脏超声,血栓部分溶解且心脏超声示右心室室壁运动功能异常,再次予重组组织型纤溶酶原激活剂40mg静脉输注行二次溶栓治疗.结果 有效率100％.1例病人出现生殖道出血,无颅脑出血等危及生命的不良反应.结论 急性肺栓塞首次予重组组织型纤溶酶原激活剂50 mg静脉溶栓,血栓部分溶解且心脏超声示右心室室壁运动功能异常者二次溶栓疗效确切,安全性好.     

小剂量rt-PA溶栓治疗急性肺栓塞效果观察

目的观察小剂量重组组织型纤溶酶原激活剂(rt-PA)溶栓治疗急性肺栓塞的疗效和安全性。方法选择急性肺栓塞患者84例,将其随机分为rt-PA组28例、UK组27例及对照组29例,rt-PA组采用小剂量rt-PA联合抗凝治疗,UK组采用尿激酶(UK)联合抗凝治疗,对照组单纯采用抗凝治疗,比较三组疗效、住院时间及不良反应及死亡情况。结果①rt-PA组治疗有效率为92.86%,与UK组的92.59%比较,差异无统计学意义(P0.05);两组与对照组比较,有效率均明显增高(P0.05)。rt-PA组与UK组住院时间比较(P0.05);与对照组比较,rt-PA组与UK组住院时间均明显缩短,差异有统计学意义(P0.05)。②三组不良反应比较,UK组发生不良反应较rt-PA组及对照组明显增多,差异有统计学意义(P0.05)。rt-PA组与UK组死亡率明显低于对照组(P0.05)。结论小剂量rt-PA治疗急性肺栓塞安全有效。     

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.     

Thrombolytic treatment of acute pulmonary embolism

Many investigators have reported about beneficial results with thrombolytic therapy in patients with acute pulmonary embolism. Streptokinase and urokinase have been used for more than 15 years, but the conditions of use of these agents still remain controversial. Optimal dosage and treatment schedule are still evolving. For streptokinase most investigators adopt a fixed dosage schedule: a loading dose of 250,000 units followed by a maintenance infusion of 100,000 units per hour for 24 to 72 hours. For urokinase numerous dosage regimens have been used such as: high dosage schedule 4,400 units per kilogram per hour for twelve to 24 hours with or without loading dose; moderate dosage 1,600 to 2,000 units per kilogram per hour for 24 hours and low dosage in bolus. With these treatments there is a trend to reduced in-hospital-mortality in massive pulmonary embolism; the early pulmonary revascularization and the hemodynamic improvement are higher than those noticed with heparin. These results are obtained with a minimum of complication essentially bleeding in 10 or 15%; most bleeding being located at puncture site. More recently, new thrombolytic agents have been used in acute pulmonary embolism. Only four studies have tested rt-PA which is effective and relatively safe, but the optimal dose regimens remain to be determined. Less information is available concerning Anisoylated Plasminogen Streptokinase Activator Complex (APSAC), the angiographic improvement seems to be rapid and important (50% on average) but the decrease of fibrinogen is important too and comparable with streptokinase. Considering the good results of thrombolytic treatment of acute submassive and massive pulmonary embolism, there is a doubt as to whether the pulmonary embolectomy has any place in the pulmonary embolism patients except in those with cardiac arrest. In the near future new thrombolytic drugs could be more efficient on pulmonary embolism and deep venous thrombosis, and thus the bleeding risk might be decreased.     

Management of mobile right heart thrombi: a prospective series

BACKGROUND: Mobile right heart thrombi (MRHT) are uncommon but their true prevalence is unknown. The aim of our study was to assess the prevalence of MRHT by a systemic use of transthoracic echocardiography in a prospective series of consecutive patients admitted for acute severe pulmonary embolism (PE) and to adopt intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) as the first line intention to treat patients with proven MRHT. METHODS AND RESULTS: We performed a systematic transthoracic echocardiogram from November 1997 to June 1999 in 335 consecutive patients admitted for suspected acute massive PE in whom the diagnosis was subsequently confirmed by perfusion lung scan or angiography. MRHT was identified in 12 of the 335 patients (4%). Nine patients presented a coil form and three patients a ball form. The thrombolytic employed in all cases was rt-PA according to the following protocol: 10 mg in a bolus and 40 mg over 2 h, followed by 50 mg over 5 h, up in a total dose of 100 mg, associated with a bolus of 5000 units of heparin. Control echocardiograms were performed 12 h after the initiation of treatment and at 12-month follow-up. Three patients died before the onset of thrombolytic infusion. The nine remaining patients were submitted to thrombolytic therapy using rt-PA. In seven of the nine remaining patients, MRHT was no longer observed after 12 h and the echocardiographic signs of RV overload had disappeared. The two last patients required adjunctive surgery because of evidence of persistent thrombus in a pulmonary artery. After 24 h, both scintigraphy and angiography demonstrated improved pulmonary perfusion. At 1-year follow-up, all patients were alive and the pulmonary artery pressure estimated by Doppler echocardiography was <30 mm Hg. CONCLUSIONS: The incidence of right heart thrombus is low in patients admitted for acute PE. Thrombolytic therapy with rt-PA appears to be rapidly effective in most patients with MRHT. The thrombus usually resolves and pulmonary perfusion is rapidly improved. Systematic echocardiogram appears to be useful for rapidly detecting MRHT in patients with suspected massive PE.     

Increase in thrombin generation after coronary thrombolysis with rt-PA or streptokinase with simultaneous heparin versus heparin alone

This study compares the extent of inhibition of thrombin generation and activity achieved in patients with acute myocardial infarction receiving fibrinolytic treatment (streptokinase SK, or rt-PA) and concomitant intravenous heparin treatment adjusted to the patients' weight with that achieved with the same heparin regimen but without fibrinolytic therapy. The study involved 90 patients, grouped according to their treatment: SK+heparin; rt-PA+heparin, and heparin without thrombolytic agents. Prothrombin fragment 1+2 (F1+2), thrombin-antithrombin complex (TAT), fibrinopeptide A (FPA) and activated partial thromboplastin time were measured. Patients treated with SK+heparin or rt-PA+heparin and higher F1+2 plasma levels than the patients treated with heparin alone at 12, 48 and 72 h in the case of SK+heparin, and at 12, 24, 48 and 72 h in that of rt-PA+heparin. Compared to baseline, the plasma levels of FPA were decreased in the three treatment groups at 24-48 h. There were no significant changes in TAT and FPA plasma levels among the three treatment groups at the different times. After thrombolytic therapy with both SK and rt-PA, there was an increase in thrombin generation, although high-dose intravenous heparin inhibited the different increases in thrombin associated with the thrombolytic agents to the same extent.     

络泰联合低分子肝素治疗急性肺栓塞的临床研究

目的评价络泰联合低分子肝素治疗急性肺栓塞的疗效。方法将确诊的102例急性肺栓塞患者分为2组,A组患者(n=55)单用低分子肝素4100IU,皮下注射,每日2次,共12天。B组患者(n=57)在A组的治疗方案的基础上,加用络泰粉剂0.8g,溶于生理盐水200m l静脉滴注,1小时滴完,每日1次。对比观察疗效。结果2组患者治疗后的各项临床和实验指标均有明显改善,A组治疗有效率为69.1%,B组为75.4%,B组的有效率明显高于A组,差异有统计学意义。鼻出血和皮下出血并发症两组无差异。结论络泰联合低分子肝素治疗急性肺栓塞是安全、有效的。