急性肺栓塞患者预后评估采用两种评分系统的价值探讨

【】目的：两种评分系统在急性肺栓塞患者预后评估中的应用价值探讨。 方法：对2012年6月~2015年6月在我院进行接治的100例疑似急性肺栓塞患者进行研究,根据患者的诊断结果分为急性肺栓塞组和非急性肺栓塞组,根据PESI评分与WELLS评分患者的入院情况以及预后进行记录分析,对两组评分系统对急性肺栓塞的诊断与预后评估进行对比分析。结果：肺栓组患者的WELLS评分明显高于非肺栓组(P<0.05),急性肺栓塞组与非肺栓塞组的WELLS等级存在明显差异(P<0.05),不同WELLS等级的急性肺栓塞患者的存活时间并无明显差异(P>0.05),患者的生存时间随着PESI等级的增高而明显缩短(P<0.05)。 结论：WELLS评分对急性肺栓塞的诊断具有良好的指导意义,对患者的预后并无指导意义,PESI评分对患者的预后有良好的指导作用,患者的生存时间随着PESI等级的增高而明显缩短。     

肺血栓栓塞症患者高敏C反应蛋白水平与肺动脉压相关性的研究

目的探讨急、慢性肺血栓栓塞症患者血清高敏C反应蛋白（high-sensitive C-reactive protein,hs-CRP）的差异及其与肺动脉压之间的相关性。方法选择肺血栓栓塞症患者102例,其中急性44例,慢性58例。所有患者均经多普勒超声心动图检查,将两组患者各自分为肺动脉压正常组与高压组,采用颗粒增强免疫透射比浊法检测hs-CRP水平。结果急性组hs-CRP（24.0±13.4 mg/L）明显高于慢性组（5.2±4.6 mg/L）（P〈0.01）。急性患者中肺动脉压正常组与高压组hs-CRP无明显差异（P=0.338）。慢性患者肺动脉压正常组hs-CRP（3.3±3.0）明显低于高压组（9.5±4.7 mg/L）（P〈0.05）。慢性肺血栓栓塞症肺动脉高压组患者hs-CRP水平和肺动脉压呈正相关（P〈0.05）。结论急性肺血栓栓塞症患者血清hs-CRP水平明显升高,慢性肺血栓栓塞症肺动脉高压组患者血清hs-CRP水平和肺动脉压显著相关。血清hs-CRP水平可用于PTE的危险分层及判断预后。     

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。     

Pulmonary hypertension secondary to minor pulmonary embolism

The response of pulmonary arterial pressure to minor degrees of pulmonary embolism was examined in 18 patients with embolic occlusion of less than 25% of the pulmonary vascular bed. Patients with pulmonary embolism were compared to normal controls matched for age and sex and to patients with a variety of acute pulmonary disorders without pulmonary embolism. Patients with pulmonary embolism and patients with other acute pulmonary diseases had significantly higher pulmonary arterial pressures and significantly lower values for arterial oxygen tension (PaO2) than did normal subjects. The degree of pulmonary hypertension correlated with the PaO2. Pulmonary hypertension occurring after minor degrees of pulmonary embolism may be a response to mild arterial hypoxemia.     

58例急性肺栓塞临床特点及疗效分析

目的 分析58例急性肺栓塞的临床特点及疗效,提高临床医生对急性肺栓塞的认识及诊治水平.方法 选择2004年至2009年11月我院和山西省阳泉市第一人民医院住院的急性肺栓塞患者58例,回顾性分析这些患者的临床表现及辅助检查、治疗方法及疗效,并进行总结归纳.结果 急性肺栓塞临床表现多样,缺乏特异性,可轻可重;检查手段有心电图、X线胸片、动脉血气分析、D2聚体、彩超、放射性核素肺通气/灌注扫描、肺动脉螺旋CT造影等.放射性核素肺通气/灌注扫描、肺动脉螺旋CT造影的特异性及灵敏度最高,溶栓治疗较单纯抗凝治疗效果更好.结论 急性肺栓塞临床谱广,表现多样,辅助检查手段多为非特异性,容易误诊、漏诊.治疗方法影响预后.     

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。     

肌钙蛋白Ⅰ检测对急性肺栓塞患者的诊断和预后评估价值

急性肺栓塞(APE)发病率和病死率高,同时漏诊率和误诊率亦较高,能对APE进行快速的危险分层诊断和预后评估对指导临床治疗相当重要。研究表明肌钙蛋白Ⅰ可用于APE的危险分层诊断,并可作为APE的独立预后评估指标,且检查方法简单、快捷、经济,其在APE患者诊治中的临床价值越来越受到重视。     

Abnormal troponin I levels in acute pulmonary embolism without abnormal concentrations of D-dimer at admission

Serum troponin I is a sensitive indicator of myocardial damage but abnormal troponin I levels have been reported without acute coronary syndrome and without cardiac damage. It has been reported that right ventricular overload and hypoxia in acute pulmonary embolism may lead to right ventricular myocardium injury reflected by elevated cardiac troponin levels and that in patients with acute central sub-massive or non-massive pulmonary embolism, even mild increase in troponin I >0.03 mug/L may provide relevant short-term prognostic information independent to clinical, laboratory and echocardiographic data. It has also been reported that patients with acute small pulmonary embolism might present with relatively low concentrations of D-dimer and it might have implications regarding the diagnostic yield of D-dimer in patients who are suspected of having an acute pulmonary embolism. We present a case of abnormal troponin I levels without abnormal concentrations of D-dimer at admission in a 26-year-old Italian man with acute pulmonary embolism. Also this case focuses attention on the importance of a correct evaluation of abnormal troponin I levels and not elevated D-dimer levels in acute pulmonary embolism.     

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。     

急性肺血栓栓塞症猪血流动力学及心肌损伤的研究

目的　观察急性肺血栓栓塞症 (PTE)猪血流动力学、动静脉血气及心肌肌钙蛋白Ⅰ(cTnⅠ )、肌红蛋白 (Mb)、肌酸激酶同工酶 (CK MB)水平。方法　健康幼年猪 16只 ,分为 2组 ,每组8只。栓塞组 (急性PTE模型组 ) :用注射器经颈外静脉插管快速 1次注入多聚乙烯微球 ,0 1g/kg体重悬浮于生理盐水 5 0ml中 ;对照组 :用注射器经颈外静脉插管快速 1次注入生理盐水 5 0ml。检测栓塞前、栓塞后即刻、30min、1h、2h、3h血流动力学及血气的变化 ,同时检测血清cTnⅠ、Mb、CK MB水平。结果　栓塞即刻肺动脉压升高 ,约为栓塞前的 2～ 3倍 ,栓塞后 2～ 3h逐渐恢复至栓塞前水平 ;心输出量、肺毛细血管嵌顿压、肺动脉压收缩压、舒张压无明显变化。栓塞即刻动脉血氧分压(PaO2 )下降 ,动脉血二氧化碳分压升高 ,pH值下降 ,30～ 6 0min达最高峰 ,2h后PaO2 和 pH值恢复至栓塞前水平。栓塞后血清cTnⅠ和Mb明显升高 ,CK Mb栓塞前后无明显变化。cTnⅠ与Mb有相关性 (r =0 5 5 ,P =0 0 0 1) ,与CK MB无相关性 (r =0 10 9,P =0 5 33)。结论　急性PTE可出现急性肺动脉压升高和气体交换障碍等病理生理改变。检测cTnⅠ和Mb有助于急性PTE心肌损伤早期诊断     

Paradoxical peripheral embolism coincident with acute pulmonary thromboembolism

Paradoxical embolism may occur in patients with acute pulmonary thromboembolism, when patent foramen ovale (PFO) coexists with pulmonary hypertension (right-left shunt). There have been few case reports of paradoxical embolism in peripheral arteries coincident with acute pulmonary thromboembolism. Here, we describe a case of paradoxical peripheral embolism associated with PFO complicated by acute pulmonary thromboembolism. The patient had severe peripheral ischemia due to a massive thrombus and was treated successfully by peripheral thrombectomy, thrombolysis, implantation of a permanent inferior vena cava filter and anticoagulation.     

Interhospital Transfer for the Management of Acute Pulmonary Embolism

BackgroundThere are increasing treatment options for the management of acute pulmonary embolism (PE), though many are only available at tertiary care centers. Patients with acute pulmonary embolism with high-risk features are often transferred for consideration of such therapies. There are limited data describing outcomes in patients transferred with acute pulmonary embolism.MethodsWe evaluated patients with acute pulmonary embolism at our tertiary care center from August 2012 through August 2018 and compared clinical characteristics, pulmonary embolism features, management, and outcomes in those transferred for acute pulmonary embolism to those that were not transferred.ResultsOf 2050 patients with pulmonary embolism included in the study, 432 (21.1%) were transferred from an outside hospital with a known diagnosis of pulmonary embolism. Patients transferred had a lower rate of malignancy (22.2% vs 33.3%; P < .001) and median Charlson comorbidity index (3 vs 4; P < .001). A higher percentage of patients transferred were classified as intermediate- or high-risk pulmonary embolism (62.5% vs 43.0%; P <.001) and more frequently received advanced therapy beyond anticoagulation alone (12.5% vs 3.2%, P < .001). Overall survival to discharge was similar between groups, though definite pulmonary embolism-related mortality was higher in the transferred group (38.5% vs 9.4%, P = .004).ConclusionMore than 1 in 5 patients treated for acute pulmonary embolism at a tertiary care center were transferred from an outside facility. Transferred patients had higher risk pulmonary embolism features, more often received advanced therapy, and had higher definite pulmonary embolism-related mortality. There are opportunities to further optimize outcomes of patients transferred for management of acute pulmonary embolism.     

血浆D-二聚体水平测定在不同肺部疾病中的临床意义

目的:探讨血浆D-二聚体(D-dimer)水平在常见肺部疾病中的差异和临床意义。方法:对236例住院治疗的肺炎、结核性胸膜炎、慢性阻塞性肺疾病、急性肺栓塞及肺癌患者的血浆D-dimer水平进行测定,分析比较血浆D-dimer水平的差异性。结果:肺炎、结核性胸膜炎、慢性阻塞性肺疾病、急性肺栓塞及肺癌组的血浆D-dimer水平与对照组比较差异有统计学意义(P<0.05)。肺炎组血浆D-dimer水平低于结核性胸膜炎、慢性阻塞性肺疾病、急性肺栓塞、肺癌组,差异有统计学意义(P<0.05)。结核性胸膜炎、慢性阻塞性肺疾病、肺癌组间血浆D-dimer水平差异无统计学意义(P>0.05)。全部急性肺栓塞患者血浆D-dimer水平升高,与结核性胸膜炎、慢性阻塞性肺疾病、肺癌组血浆D-dimer水平差异有统计学意义(P<0.05)。结论:肺炎、结核性胸膜炎、慢性阻塞性肺疾病、肺栓塞及肺癌都可引起凝血机制的异常,引起血浆D-dimer水平的升高,但在急性肺栓塞中最为明显。血浆D-dimer水平的升高不是诊断急性肺栓塞的特异性指标,其临床价值在于阴性排除结果。     

Acute pulmonary embolism in pediatric patients awaiting heart transplantation

Acute pulmonary embolism with infarction can delay urgently needed heart transplantation and increase the postoperative pulmonary complications. Few data are available concerning pulmonary embolization in the pediatric patient with end-stage congestive heart failure. Sixty-two consecutive pediatric patients awaiting heart transplantation were monitored for evidence of acute pulmonary embolism. Acute pulmonary infarction was documented by ventilation-perfusion scan, pulmonary angiography or pathologic examination in six patients. The prevalence differed by diagnosis; 5 of 36 patients with dilated cardiomyopathy and 1 of 20 patients with congenital heart disease developed acute pulmonary embolism with infarction. No significant difference in age at the time of transplantation evaluation, duration of congestive heart failure, presence of cardiac arrhythmias or degree of cardiac dysfunction was seen between patients with and without pulmonary embolism. Two-dimensional echocardiography failed to detect the presence of an intracardiac thrombus in four of the six patients. Two patients who developed acute pulmonary infarction are alive after successful heart transplantation. The remaining four patients died within 6 weeks of initiation of anticoagulant therapy before transplantation could safely be performed. In summary, pediatric patients with end-stage congestive heart failure are at risk for acute pulmonary embolism. No specific clinical factor identified those patients who developed acute pulmonary infarction. Anticoagulant therapy is strongly recommended in the pediatric patient with poor ventricular function awaiting heart transplantation.     

NT-proBNP与cTnⅠ在评估老年中高危肺栓塞合并右心功能障碍患者病情中的应用价值

目的 探讨血浆N末端B型利钠肽原(NT-proBNP)、心肌肌钙蛋白Ⅰ(cTnⅠ)在评估老年急性中高危肺栓塞合并右心功能障碍患者病情中的应用价值.方法 选取2015年1月至2016年6月新疆医科大学第一附属医院收治的老年急性中高危肺栓塞合并右心功能障碍的59例患者作为合并组,另选取85例未发生右心功能障碍的老年急性中高危肺栓塞患者作为非合并组,以及50名体检健康者作为对照组.采集所有研究对象清晨空腹外周静脉血,应用免疫荧光法测定患者血浆NT-proBNP及cTnⅠ指标,采集血液标本的同时进行超声心动图检查,对比各组NT-proBNP、cTnⅠ指标的差异性,并应用特征曲线分析影响急性中高危肺栓塞患者临床预后结局的主要因素.结果 3组NT-proBNP、cTnⅠ指标比较差异均有统计学意义(P值均＜0.05),并且合并组患者右心室舒张末期内径明显高于非合并组与对照组(P值均＜0.05).受试者工作特征曲线显示NT-proBNP、cTnⅠ曲线下面积均大于90％,logistic回归分析显示NT-proBNP、cTnⅠ指标、右心功能障碍与患者临床预后具有密切联系.结论 NT-proBNP、cTnⅠ指标不仅在诊断急性中高危肺栓塞合并右心功能障碍中具有重要意义,同时能够对患者的临床预后转归提供良好、准确的评估,可作为指导肺栓塞患者临床治疗的简单、灵敏的标志物.     

Contribution of pulmonary vasoconstriction to haemodynamic instability after acute pulmonary embolism. Implications for treatment?

Acute pulmonary embolism with haemodynamic instability has a high mortality rate. Death results from an acute increase in right ventricular afterload, and the commonly held view is that mechanical obstruction of the pulmonary vascular bed is largely responsible for this increase. In accordance, recent treatment guidelines for severe pulmonary embolism focus exclusively on interventions aimed at relieving this mechanical obstruction, either by thrombolysis or (catheter) embolectomy. However, there is evidence to indicate that vasoconstriction is a very important contributor to the initial increase in pulmonary vascular resistance after pulmonary embolism. This is consistent with the observation that the degree of mechanical obstruction correlates at best poorly with haemodynamic manifestations. Thromboxane A(2) and serotonin are probably mainly responsible for pulmonary vasoconstriction. Cyclooxygenase inhibitors and serotonin antagonists have been shown in animal experiments to attenuate the haemodynamic response to acute pulmonary embolism and to reduce mortality. In addition, reports of a favourable response to pulmonary vasodilators in animals and in humans with acute severe pulmonary embolism have been published. In this paper, it is argued that we may need to reconsider our current therapeutic approach to patients with acute severe pulmonary embolism. Antagonising pulmonary vasoconstrictive mediators or administering pulmonary vasodilators may prove to be life-saving interventions in these patients.     

Pulmonary embolism: differences in presentation between older and younger patients

BACKGROUND: the incidence of pulmonary embolism increases with age but the 'classical' presentation of acute pulmonary embolism may not occur in older persons. OBJECTIVES: to compare the clinical presentation of younger and older patients with acute pulmonary embolism. DESIGN: retrospective identification of 60 consecutive cases of spiral computed tomography confirmed acute pulmonary embolism over a 3-year period, with blinded review of radiological films and electrocardiographs, and analysis of clinical presentation. SETTING: a district general hospital serving a population of 200,000 people. SUBJECTS: 31 younger and 29 older patients with acute pulmonary embolism. RESULTS: older persons less often complained of pleuritic chest pain (P < 0.02), particularly as their primary presenting complaint (P < 0.002). Twenty-four percent of older but just 3% of younger persons presented with collapse (P < 0.02), despite similar proportions of central and peripheral emboli in the two groups. Older persons were more often cyanosed (P = 0.05) and hypoxic (P < 0.04) than younger persons but there were no significant differences with respect to heart rate, respiratory rate or mean arterial blood pressure. CONCLUSIONS: older people present atypically with acute pulmonary embolism, potentially leading to delays in diagnosis and initiation of treatment. Collapse is a particularly important symptom of acute pulmonary embolism in older persons, even in the absence of pain.     

A case of acute pulmonary embolism and acute myocardial infarction with suspected paradoxical embolism after laparoscopic surgery

Summary We describe the case of a 59-year-old Japanese man who had an acute pulmonary embolism in addition to acute myocardial infarction after a laparoscopic cholecystectomy. The posterior descending coronary artery was totally occluded, and direct percutaneous transluminal balloon angioplasty was performed. The pulmonary embolism was diagnosed by lung perfusion scanning and was treated with anticoagulant therapy. A patent foramen ovale and right-to-left atrial shunting of blood were detected by contrast transesophageal echocardiography. Paradoxical embolism is a rare complication of pulmonary embolism and may have been responsible for the acute myocardial infarction in our patient.     

Correlated expression of D-dimer concentrations with thrombotic burden in acute pulmonary embolism.

Thrombotic burden might have an influence upon the concentration of D-dimer in patients with acute pulmonary embolism. Patients with small pulmonary embolisms may thus present with relatively low concentrations of D-dimer. The objective of this study was to assess the correlation of the concentrations of D-dimer with the pulmonary artery occlusion score (PAOS) in a cohort of patients with acute pulmonary embolism. We have presently studied the correlation between the concentrations of D-dimer and the PAOS in a group of 75 patients who presented to the Department of Emergency Medicine with a clinical picture suggestive for acute pulmonary embolism and whose pulmonary computerized tomography (CT) angiography was positive for pulmonary embolism. A significant (P < 0.001) correlation (r = 0.42) was noted between the concentration of D-dimer and the PAOS in this group of 75 patients with acute pulmonary embolism. We further divided the cohort into those patients who had a score below the median of 18 (n = 37) and those who had a score above the median (n = 38), the corresponding mean concentrations of D-dimer being 364 and 814 ng/ml, respectively, in contrast to a mean concentration of 285 ng/ml that was observed in the group of controls (n = 73). In addition, from the receiver-operated characteristic (ROC) curves that were produced for the purpose of differentiating between the presence or absence of pulmonary embolism, for those who had a low score it was not possible to differentiate between those who had or did not have a pulmonary embolism [area under the curve 0.595 as opposed to 0.835 (P < 0.001) for the group with the high score]. Patients with acute small pulmonary embolism might present with relatively low concentrations of D-dimer. These findings might have implications regarding the diagnostic yield of D-dimer in patients who are suspected of having an acute pulmonary embolism.     

Prevalence of duplex ultrasonography detectable venous thrombosis in patients with suspected or acute pulmonary embolism

OBJECTIVES: Duplex ultrasonography performance in detecting embolic foci has not been proven satisfactory compared with phlebography or autopsic findings. In case of suspected pulmonary embolism, the embolic focus is only discovered in 11 to 18% of the cases compared with more than 30% with phlebography. For overt acute pulmonary embolism, the discovery rate is in the 30 to 45% range versus 70 to 80% with phlebography or autopsy findings. This discrepancy might result from the fact that duplex ultrasonographic explorations are generally limited to the deep collectors at the cruropopliteal level. The purpose of this study was to assess the prevalence of duplex ultrasonography detected venous thrombosis in patients with suspected or acute pulmonary embolism when the exploration includes the entire venous system from the inferior vena cava to the ankles and examines not only the deep collectors but also the muscle and superficial networks.MATERIAL AND METHODS: This study included all patients with suspected pulmonary embolism referred to the emergency unit from January 1, 1995 through December 31, 1998. The patients' hospital files were used to determine the suspected pulmonary embolism population. The acute pulmonary embolism population was defined as the patients whose files contained documented proof of pulmonary embolism (highly probable ventilation/perfusion pulmonary scintigraphy, positive pulmonary angiography, positive proximal angioscan). Thrombosis of the deep venous collectors with or without associated superficial or muscular localization was classed as "deep venous thrombi" and superficial or muscular thrombosis without involvement of the deep collectors was classed as "other venous thrombi". Subpopliteal thrombosis was classed as distal and popliteal or suprapopliteal thrombosis as proximal.RESULTS: The suspected pulmonary embolism group included 352 patients, 118 men and 234 women aged 67.6 +/- 15.4 and 70.8 +/- 20.0 years respectively (m +/- SD). The acute pulmonary embolism group included 60 patients, 17 men and 43 women aged 66.2 +/- 12.5 and 69.7 +/- 16.6 years respectively. Overall prevalence of duplex-ultrasound detected venous thrombosis was 30.4% (107/352) (95%CI: 25.6-35.2) in the suspected pulmonary embolism group and 80% (48/60) (95%CI: 69.9-90.1) in the acute pulmonary embolism group. Deep venous thrombi reaching the collectors and proximal thrombi predominated. Prevalence of "other venous thrombi" and distal venous thrombi were 6.5% (23/352) and 11.4% (40/352) respectively in the suspected pulmonary embolism group and 15.0% (9/60) and 26.7% (16/60) in the acute pulmonary embolism group. The frequency of asymptomatic venous thrombosis of the lower limbs, irrespective of the localization, was 42.1% (45/107) in the suspected pulmonary embolism group and 52.1% (25/48) in the acute pulmonary embolism group.CONCLUSIONS: The prevalence of duplex-ultrasonography detected venous thrombosis in patients with suspected or proven pulmonary embolism found in this series was equivalent to the rates reported in phlebography and autopsy series. The prevalence was higher than usually reported for duplex-ultrasonography studies limited to the cruro-popliteal level. The difference came from the "other venous thrombi" and "distal deep venous thrombi" discovered by exploring the superficial and muscular networks and the calves. This study demonstrates the contribution of duplex-ultrasonography to the diagnostic strategy for pulmonary embolism.