Right ventricular responses to massive and submassive pulmonary embolism

It is critically important to quickly recognize and treat acute pulmonary embolism (PE). Submassive and massive PEs are associated with right ventricular (RV) dysfunction and may culminate in RV failure, cardiac arrest, and death. A rapid and coordinated diagnostic and management approach can maximize success and save lives.     

Improving adjunctive treatment in pulmonary embolism and fibrinolytic therapy. The role of enoxaparin and weight-adjusted unfractionated heparin

Aim The role of enoxaparin and weight-adjusted unfractionated heparin (UH) as adjunct to fibrinolytic therapy in pulmonary embolism is unknown. Methods In a prospective, open-label, controlled multicenter trial, 80 patients with high-risk pulmonary embolism were enrolled. Forty patients received alteplase infusion plus weight-adjusted UH (24–48 h) and then enoxaparin (7 days). In control group, UH standard regimen was used. There were not differences on pulmonary embolism extension, (P 0.63) and right ventricular hypokinesis (P 0.07) in both groups. In terms of in-hospital survival (P 0.009), escalation treatment (P < 0.001) and in-hospital stay (P < 0.001) study group had better outcome than opposite group. In a 30 (P < 0.001) and 90 (P < 0.001) days follow-up pulmonary perfusion was improved in patients who received enoxaparin versus heparin alone without increasing major bleeding complications. Conclusion Enoxaparin and weight-adjusted intravenous UH as adjunct to 1-h alteplase infusion improve in-hospital and follow-up outcome compared to heparin alone in high-risk PE. This paper was written with unforgettable memory of Hector Garcia.     

Enlarged right ventricle without shock in acute pulmonary embolism: prognosis

Objective

An unsettled issue is the use of thrombolytic agents in patients with acute pulmonary embolism (PE) who are hemodynamically stable but have right ventricular (RV) enlargement. We assessed the in-hospital mortality of hemodynamically stable patients with PE and RV enlargement.

Methods

Patients were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis II. Exclusions included shock, critical illness, ventilatory support, or myocardial infarction within 1 month, and ventricular tachycardia or ventricular fibrillation within 24 hours. We evaluated the ratio of the RV minor axis to the left ventricular minor axis measured on transverse images during computed tomographic angiography.

Results

Among 76 patients with RV enlargement treated with anticoagulants and/or inferior vena cava filters, in-hospital deaths from PE were 0 of 76 (0%) and all-cause mortality was 2 of 76 (2.6%). No septal motion abnormality was observed in 49 patients (64%), septal flattening was observed in 25 patients (33%), and septal deviation was observed in 2 patients (3%). No patients required ventilatory support, vasopressor therapy, rescue thrombolytic therapy, or catheter embolectomy. There were no in-hospital deaths caused by PE. There was no difference in all-cause mortality between patients with and without RV enlargement (relative risk = 1.04).

Conclusion

In-hospital prognosis is good in patients with PE and RV enlargement if they are not in shock, acutely ill, or on ventilatory support, or had a recent myocardial infarction or life-threatening arrhythmia. RV enlargement alone in patients with PE, therefore, does not seem to indicate a poor prognosis or the need for thrombolytic therapy.     

手术后并发急性大面积肺血栓栓塞患者溶栓治疗的效果

目的：了解手术后发生急性大面积肺血栓栓塞患者进行静脉溶栓治疗的安全性及经验.方法：收集我科5例手术后6d内发生急性大面积肺血栓栓塞患者的临床资料,在评估其出血风险后给予阿替普酶50 mg缓慢静脉溶栓治疗,观察治疗后患者症状、生命体征和临床指标及出血情况.结果：5例患者均接受了静脉溶栓治疗,其症状和临床指标均明显好转出院,未见溶栓后手术伤口大出血及其他危险情况.仅有1例患者出现伤口处出血,在停用溶栓药物,加强对症处理后好转.结论：对于手术后近期急性大面积肺血栓栓塞患者,在评估其总体出血风险较低后,可在严密监测下进行溶栓治疗,能改善患者预后,不增加患者大出血的风险.     

中高危组肺栓塞溶栓治疗的有效性和安全性

对于中高危组急性肺栓塞的治疗,长期以来国内外肺栓塞诊疗指南都推荐单纯抗凝治疗,但临床上一直存在争议。争议的焦点主要是溶栓治疗的有效性和安全性。近年来的大多数随机对照临床试验证实,中高危组急性肺栓塞溶栓治疗确实难以降低患者病死率,但是可以更快降低肺动脉压和改善右心室功能,而且能够降低血流动力学代偿失调的发生率。与单纯抗凝治疗相比,虽然溶栓治疗增加危害性很小的轻微出血(minor bleeding)发生率,但并不增加严重出血(major bleeding)发生率,安全性较好。     

病态肥胖肺栓塞患者肝素抗凝剂量的探讨（病例报告及文献复习）

目的：探讨病态肥胖肺栓塞患者抗凝治疗时普通肝素的治疗剂量。方法报告1例病态肥胖(体质量>100 kg,体质量指数>40 kg/m2)的肺栓塞患者,并进行文献复习,结合本患者和文献资料分析肝素抗凝治疗过程中肝素初始剂量、维持剂量与体质量的关系。结果患者男,21岁,身高178 cm,体质量140 kg,因“晕厥3 h”入院,肺动脉 CT 血管造影确诊为急性肺栓塞。立即按校正体质量106 kg [(实际体重+理想体重)/2]给予负荷剂量普通肝素80 U/kg,续以18 U·kg-1·h-1持续泵入,4 h 后查活化部分凝血活酶时间(APTT)为145 s;暂停肝素泵入1 h,复查 APTT 为96 s;继续暂停肝素泵入1 h,APTT 为56 s;开始以1500 U/h 泵入肝素,根据 APTT 值调整肝素泵入速度,最终肝素维持用量为9.4~14.6 U·kg-1·h-1(按校正体质量计算),APTT 维持在45~96 s。复习文献：病态肥胖患者肝素按 Raschke 量表负荷和维持治疗,会出现 APTT 超标和达标时间延长。按照校正体质量′[理想体质量+0.3×(实际体质量-理想体质量)]计算,80 U/kg 为负荷剂量,13 U·kg-1·h-1为维持剂量,可能能减少病态肥胖患者肝素治疗时 APTT 的超标几率,增加安全性。结论肝素抗凝时 Raschke 量表不适合病态肥胖肺栓塞患者,应适当降低肝素的负荷剂量和维持剂量。     

Caution for acute submassive pulmonary embolism with syncope as initial symptom: a case report

Pulmonary embolism (PE) may escape prompt diagnosis since clinical symptoms and signs are nonspecific. The occurrence of syncope as the sole initial symptom in a previously healthy patient with no predisposing factors to embolism and no hemodynamic instability is extremely rare, which may have been a factor in the delayed diagnosis. We describe a case of acute submassive PE with syncope as the initial symptom. A 62-year-old previously healthy female was admitted to our hospital for transitory episode of syncope. Following admission, chest computed tomography demonstrated embolism in the right main pulmonary and left inferior pulmonary arteries. Following the final diagnosis, the patient was successfully treated with thrombolytic therapy with systemic urokinase. We consider that raised awareness and early diagnosis and treatment were key factors in ensuring a satisfactory prognosis.     

慢性阻塞性肺疾病急性加重疑诊合并肺栓塞的抗凝治疗临床分析

目的 探讨对重度慢性阻塞性肺疾病急性加重(acute exacerbation of chronic obstructive pulmonary disease,AECOPD)疑诊合并肺栓塞(PE)患者进行抗凝治疗的有效性和安全性.方法 将D-二聚体阳性的37例重度AECOPD患者分为血氧分压正常组(A组)和血氧分压降低组(B组),并对两组患者进一步随机分为抗凝(A1、B1)和非抗凝(A2、B2)两个亚组.分别观察和评估A组和B组抗凝和非抗凝治疗的临床变化.结果 B1,组和B2组比较:临床症状改善、动脉血气分析、D-二体和机械通气时间等比较差异有统计学意义(P＜0.05),两组并发症比较差异无统计学意义(P＞0.05),B1组优于B2组·结论具有静脉血栓栓塞高危因素或临床高度可疑PE、D-二体检测阳性的重度AECOPD机械通气患者,若同时存在低氧血症,特别是存在经持续鼻导管吸氧或无创机械通气难以纠正的低氧血症时,在排除急性左心衰和气胸后,不必等待CTPA或核素肺通气/灌注显像检查确诊,而应当即刻开始给予常规抗凝治疗.     

溶栓与单纯抗凝治疗急性次大面积肺栓塞的疗效及安全性

目的：探讨溶栓与单纯抗凝治疗急性次大面积肺栓塞患者的疗效与安全性。方法：63例急性次大面积肺血栓栓塞症患者,被随机分为溶栓组（n＝32）与单纯抗凝组（n＝31）。观察两组治疗前与治疗2周后动脉血气指标及右心功能指标变化,进行疗效分析。统计两组出血、血小板减少发生情况。结果：治疗后两组动脉血气指标及右心功能指标较治疗前显著改善（P＜0.05或＜0.01）;与单纯抗凝组比较,溶栓组动脉血氧分压[PaO2,（77.8±7.3）mmHg比（83.4±8.7）mmHg]、右室前壁活动度[RVAWM,（4.9±1.7）mm比（5.8±2.2）mm]显著上升,肺泡-动脉血氧分压差[P （A-a）O2,（23.1±2.8）mmHg比（16.5±2.4）mmHg]、肺动脉收缩压[PASP,（54.6±7.9）mmHg比（34.2±7.5）mmHg]显著下降（P＜0.05或＜0.01）。溶栓组总有效率显著高于单纯抗凝组（100％比80.6％,P＝0.002）。两组出血发生率及血小板减少发生率无统计学差异（P＞0.05）。结论：溶栓治疗可显著降低急性次大面积肺栓塞患者的肺动脉压力,改善氧合及右室功能指标,无禁忌患者可考虑优先推荐。     

Recombinant tissue-type plasminogen activator followed by heparin compared with heparin alone for refractory unstable angina pectoris

Patients with unstable angina pectoris who remain symptomatic despite medical treatment are at high risk of death and myocardial infarction. The incidence of refractory unstable angina was examined in a consecutive series of 103 patients who received conventional medical treatment with nitrates, beta blockers, calcium antagonists and aspirin. During 48 hours of continuous electrocardiographic monitoring, 24 patients had greater than or equal to 1 anginal attack, 5 of whom had both painful and painless ischemic episodes. In these 24 patients with unstable angina refractory to conventional medical treatment, the short-term efficacy of recombinant tissue-type plasminogen activator (rt-PA) followed by heparin was assessed and compared with heparin alone in a randomized double-blind trial. Recurrences of ischemic attacks during a 72-hour follow-up period were documented in 9 of the 12 patients given heparin alone. All patients experienced at least 1 symptomatic ischemic episode and 1 patient had both painful and painless ischemia. No patient given rt-PA plus heparin had either symptomatic or asymptomatic ischemic attacks during follow-up. Kaplan-Meier curves analysis demonstrated a significantly higher probability of being ischemia free in the group of patients treated with rt-PA followed by heparin than in the group treated with heparin alone (p less than 0.01). Quantitative coronary arteriography failed to reveal any significant changes of ischemia-related lesions before and after each treatment. This study demonstrates that the combination of rt-PA and heparin has a greater protective effect than heparin alone in treating recurrent ischemic episodes in patients with refractory unstable angina.(ABSTRACT TRUNCATED AT 250 WORDS)     

Novel management strategy for patients with suspected pulmonary embolism.

AIMS: A simple management strategy is required for patients with acute pulmonary embolism which allows a rapid and reliable diagnosis in order to start timely and appropriate treatment. METHODS AND RESULTS: Two hundred and four consecutive patients with suspected pulmonary embolism were managed according to a standardized protocol based on the clinical pretest probability and the initial haemodynamic presentation (shock index=heart rate divided by systolic blood pressure). Patients with a high pretest probability and a positive shock index (> or =1) (n=21) underwent urgent transthoracic echocardiography. Based on the presence or absence of right ventricular dysfunction, reperfusion treatment was initiated immediately. Patients with a negative shock index (<1) (n=183) underwent diagnostic evaluation including pretest probability, D-dimer, and spiral computed tomography (CT) as first-line tests. Echocardiography was performed only when a central pulmonary embolism was found in the spiral CT(n=33). According to our strategy, 98 patients met the diagnostic criteria of pulmonary embolism: 75 patients (all shock index <1) were treated with heparin alone, 16 (seven had a shock index > or =1) with thrombolysis, four (all shock index > or =1) with catheter fragmentation, and three (all shock index > or =1) with surgical embolectomy. The all-cause mortality rate at 30 days was 5%, and at 6 months 11%. Right ventricular dysfunction on baseline echocardiography was not associated with a higher mortality rate at 6 months (logrank 2.4, P=0.12). CONCLUSIONS: The novel management strategy for patients with suspected pulmonary embolism resulted in a rapid diagnosis and treatment with a low 30-day mortality. In patients with pulmonary embolism and a positive shock index, time-consuming imaging tests can be avoided to reduce the risk of sudden death and not to delay reperfusion therapy.     

Prognostic importance of quantitative echocardiographic evaluation in patients suspected of first non-massive pulmonary embolism

Aims: Patients suspected of acute pulmonary embolism (PE) frequentlyundergo echocardiography as a part of the initial work-up. Prognosticimplication of routine echocardiography in patients suspectedof PE remain to be established. Methods and results: Transthoracic echocardiography, including tissue Doppler imaging,was performed in 283 consecutive patients referred for ventilation/perfusionscintigraphy (V/Q scan) on suspicion of first non-massive PE.The prognostic information of quantitative measures of rightventricular (RV) size, function, and pressure was assessed.Patients with PE had a follow-up echocardiography after 1 yearand changes in the parameters were assessed. Patients with PE and normal V/Q scans had similar age-adjusted1 year mortality [10 and 12%, NS (not significant)], althoughpatients with indeterminate scans carried a poorer prognosis(16% survival, P = 0.0004). Among all patients left ventricular(LV) ejection fraction as well as shortening of the pulmonaryartery (PA) acceleration time (a measure of RV after-load) wasassociated with increased mortality [hazard ratio (HR) = 0.84per 10 ms increase, P < 0.0001]. In patients with confirmed PE, the PA acceleration time is predictiveof event-free survival (all-cause mortality and heart failurehospitalizations) adjusted for LV ejection fraction, age, andsex (HR = 0.78 per 10 ms increase, P = 0.04). Measures of regional myocardial function were not related tooutcome in this study, regardless of presence of PE. Conclusion: PA acceleration time and LV systolic function are independentpredictors of mortality in patients suspected of PE, and areindependent predictors of event-free survival in patients withconfirmed PE.     

Thrombolysis in acute nonmassive pulmonary embolism: potential role of multidetector-row spiral computed tomography in decision making

In the setting of suspected or confirmed nonmassive pulmonary embolism (PE), transthoracic echocardiography (TTE) is an important tool to identify patients who could benefit from thrombolytic therapy, because of right ventricle (RV) dysfunction, and to monitor the dynamic response of the RV to reperfusion therapy. Unfortunately, certain patient characteristics such as obesity, lung disease, postsurgical state, or respiratory distress often lead to inadequate ultrasonographic imaging quality. In such patients, multidetector-row spiral computed tomography (MSCT) may become even more important. We present a female obese patient with acute nonmassive PE in whom TTE did not allow a reliable evaluation of the RV. Conversely, MSCT, beyond a direct demonstration of intravascular thrombi, detected multiple signs suggesting RV dysfunction. According to these findings, thrombolysis was safely performed, obtaining a rapid clinical improvement and a regression of RV dysfunction.     

53例急性肺栓塞心电图分析

目的分析和总结肺栓塞时的心电图特点及其在急性肺栓塞的诊断与鉴别诊断中的应用。方法回顾性分析6年来我院确诊的53例急性肺栓塞患者住院期间的心电图表现并对每位患者治疗前后的心电图形进行对比。结果 53例患者中,出现心电图改变者占98.14%,窦性心动过速最多占77.35%,其次是ST-T改变(ST段改变占64.15%,T波改变占62.26%),典型SⅠQⅢTⅢ征者占22.64%,肺型P波占7.55%,完全性或不完全性右束支阻滞的占18.87%,aVR导联出现终末R波占28.30%。经溶栓抗凝治疗后,比对原有心电图上述项目皆发生了动态变化过程。结论心电图对于提示肺栓塞的诊断有一定的临床价值重大意义。     

Liver dysfunction in patients with acute pulmonary embolism

Aim: Although liver injury due to cardiac, chronic respiratory and circulatory failure has been reported, this has yet to be studied in patients with pulmonary embolism (PE). We investigated liver injury in patients with acute PE. Methods: We retrospectively reviewed 107 acute PE patients over a two‐year period. Patients were categorized as having: (1) severe (P_aO₂ < 45 mmHg), moderate (45 mmHg ≤ P_aO₂≤ 60 mmHg) or mild hypoxemia (60 mmHg < P_aO₂ < 80 mmHg) groups; (2) massive and non‐massive PE; (3) absence or presence of pre‐existing cardiopulmonary disease; and (4) absence or presence of right ventricle dysfunction. Serum levels of liver enzymes were compared between groups. Results: Transaminase levels were higher in severe hypoxemia patients compared mild hypoxemia patients (p=0.045 and p=0.036). Albumin and bilirubin levels were lower and higher, respectively, in patients with severe and moderate hypoxemia compared to mild hypoxemia patients (p < 0.05 and p < 0.01). There was a negative correlation between hepatic markers and P_aO₂ and %S_aO₂: r=–0.212, p=0.032 between AST and %S_aO₂; r=–0.243, p=0.013 and r=–0.241, p=0.014 between ALT and P_aO₂ and %S_aO₂; and r=–0.224, p=0.024 and r= –0.283, p=0.004 between direct bilirubin and P_aO₂ and %S_aO₂. AST and ALT levels were higher in massive PE than non‐massive PE patients (p=0.0001). Albumin levels were lower in patients with right ventricle dysfunction than in those without (p=0.02). One (0.9%) had a clinical picture of hypoxic hepatitis. Conclusion: Abnormal LFTs showed a mixed pattern in patients with acute PE.     

Echocardiographic and functional cardiopulmonary problems 6 months after first-time pulmonary embolism in previously healthy patients.

AIMS: We hypothesized that first-time submassive pulmonary embolism (PE) can cause persistent, significant cardiopulmonary problems, including right ventricular damage and worsened quality of life in patients with no prior cardiopulmonary disease. METHODS AND RESULTS: We prospectively enrolled 205 patients without end-stage comorbidity diagnosed with submassive PE (systolic blood pressure always > 100 mmHg). Using explicit criteria, we identified a subgroup of 127 'previously healthy' patients who were free of cardiopulmonary disease or other disabling process. All patients had transthoracic echocardiography (echo) at the time of diagnosis. Six months later, survivors returned for repeat echo, 6 min walk distance (6MWD), and a quality-of-life survey. We defined a significant cardiopulmonary problem as either: (i) abnormal RV on echo (RV dilation or RV hypokinesis); or (ii) NYHA score > II or a 6MWD < 330 m at 6 months. Of 127 study patients, five had inadequate echos, nine were lost to follow-up, and four died, leaving 109 with complete data. Of 109 patients, 45 (41%) had cardiopulmonary problems 6 months after PE: 18 of 109 (17%) had only an abnormal RV, 18 of 109 (17%) had only functional limitation, and nine of 109 (8%) had both. Twenty-two patients (20%) indicated at least one index of poor quality-of-life: health status worse, not currently shopping, or perceived need for oxygen at home. Patients with cardiopulmonary problems demonstrated a significant decrease in SaO(2)% after 6MWD (97 +/- 1.3 pre-6MWD vs. 96 +/- 1.8% post-6MWD, P = 0.004 by paired t-test). CONCLUSION: Six months after first-time PE, 41% of previously healthy patients had either an abnormal RV on echo, an NYHA score > II or a 6MWD < 330 m. Treatment studies of PE should include these persistent cardiopulmonary problems as study endpoints.     

肺结核并发肺栓塞的诊断与治疗

目的探讨肺结核并发肺栓塞(pulmonary embolism,PE)的诊断与治疗方法。方法分析2002年6月—2005年6月诊治的5例肺结核并发PE病例的临床资料。结果5例患者肺结核并发PE后,咳嗽、咳痰、发热加重,并出现胸闷、胸痛、心悸、呼吸困难,查体为呼吸急促、心动过速。经多普勒超声心动图、螺旋CT肺动脉造影检查明确PE诊断。5例确诊时间均已超过溶栓时间,其中1例转外科手术治疗后应用抗凝药物治疗,余4例均给予抗结核治疗同时抗凝治疗。其中1例未坚持服用抗凝药物,2年后再次复发PE抢救无效死亡,余4例病情好转。结论肺结核可并发PE,因临床症状类似,易延误诊断,错过溶栓时间,PE诊断以影像学检查为主,抗凝治疗是最佳治疗方法。     

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。