简化肺栓塞严重程度指数评分对≥80岁非高危肺栓塞患者危险分层的应用价值

目的探讨简化肺栓塞严重程度指数(sPESI)评分在≥80岁非高危肺栓塞(PE)患者危险分层中的应用价值。方法连续选取近8年于北京同仁医院住院的141例≥80岁非高危PE患者,根据2019年欧洲指南标准将患者分为低危组53例,中低危组75例,中高危组13例。运用PESI评分、sPESI评分、Bova评分、PREP评分、肺栓塞风险评分(PERS)五种量表进行测评,对比各量表测评结果,并根据30 d死亡情况判断五种量表的预后效果。结果 141例患者中,30 d内死亡10例(7.09%)。PESI、sPESI、Bova评分、PREP评分、PERS五个量表的受试者工作特征(ROC)曲线下面积(AUC)分别为0.687、0.802、0.786、0.769、0.668,差异有统计学意义(P0.05),其中sPESI的AUC值最大。sPESI量表的灵敏度最高为0.951,PREP量表的特异度最高为0.905,PESI量表的Youden指数最大,为1.526。结论 sPESI评分、PREP评分和PESI评分各有优缺点,但PESI评分的灵敏度最高,AUC最大,可用于≥80岁群体的早期危险分层评估,但因其特异性较低,故临床应用时建议联合其他评分方法一起评估。     

80岁及以上老年女性肺血栓栓塞症患者的临床特点分析

目的探讨女性与男性高龄肺血栓栓塞症(PTE)患者的危险因素、辅助检查及病情严重性的差异。方法回顾性分析我院住院的高龄PTE患者119例,女性72例,男性47例,比较女性与男性临床症状、既往病史、实验室检查、影像学检查、治疗方案及危险分层的差异。进行危险分层综合评估、危险分层评分[包括肺栓塞严重程度指数(PESI)和简化版PESI(sPESI)]及预后评分。结果与男性比较,女性吸烟、血红蛋白、肌酐及心房颤动比例明显降低,既往PTE、淋巴细胞、心电图V2、V3导联T波改变及口服抗凝药物比例明显升高(P0.05,P0.01)。女性PESI评分明显低于男性[86.5(82.0,101.8)分vs 102.0(94.0,112.0)分,P0.01]。女性与男性临床症状、sPESI、预后评分及危险分层综合评估比较,无统计学差异(P0.05)。结论高龄女性与男性PTE患者相比,心电图胸前V2、V3导联T波改变多见,高龄PTE患者临床症状、各类预后评分分值及危险分层无性别差异。     

简化肺栓塞严重程度指数在老年非高危肺血栓栓塞症患者中的应用

目的探讨简化肺栓塞严重程度指数(sPESI)在年龄80岁非高危肺血栓栓塞症(PTE)患者中的应用特点。方法选择本院住院治疗的年龄≥60岁的老年PTE患者223例,分为年龄80岁组78例和年龄≤80岁组145例,回顾分析患者临床资料及sPESI与老年PTE中危分层的相关性,比较2组危险分层、sPESI以及30d病死率的差异。结果 sPESI与中危分层呈正相关(r=0.18,P=0.03)。与年龄≤80岁组比较,年龄80岁组低危比例明显降低(0vs 61.4%),中低危和中高危比例升高(50.0%vs 22.8%,50.0%vs 15.8%,P0.01);且sPESI显著升高[(1.91±0.76)分vs(0.51±0.43)分,P0.01]。去掉年龄因素重新计算sPESI后,年龄80岁组低危比例显著低于年龄≤80岁组(P0.01),中高危比例显著高于年龄≤80岁组(P0.01),且年龄80岁组sPESI显著高于年龄≤80岁组[(0.91±0.74)分vs(0.51±0.43)分,P0.01]。sPESI预测年龄80岁组和年龄≤80岁组的30d死亡风险的曲线下面积分别为0.692(95%CI:0.627~0.752)和0.803(95%CI:0.729~0.864,P0.05)。结论 sPESI可评价年龄80岁非高危PTE患者的严重程度,能为临床治疗和预后判断提供客观依据。     

中危肺栓塞患者30天内不良预后的预测因素分析

目的：探讨中危肺栓塞早期不良结局的危险因素及可能的预测因素。方法：连续性纳入2016年1月至2021年12月,在我院住院的209例中危肺栓塞患者,按照30d是否存在不良预后分为短期不良结局组和存活组,应用多因素Logistic分析中危肺栓塞早期不良结局的危险因素;应用ROC曲线分析危险因素联合简化版肺栓塞严重程度评分（simplified pulmonary embolism severity index,sPESI）对中危肺栓塞患者早期不良结局的预测价值。结果：多因素Logistic回归分析得出sPESI评分、NLR为预测中危肺栓塞早期不良结局的危险因素（P<0.05）。将NLR≥3.79作为新的指标,计为1分,纳入NLR的sPESI评分预测中危肺栓塞早期不良结局预测价值的ROC曲线下面积为0.968(95%CI:0.932～0.988),当评分≥2分时,灵敏度为100%,特异度为80.61%。结论：纳入NLR的s PESI评分对中危肺栓塞患者早期不良结局具有一定的预测价值。     

年龄对非高危肺血栓栓塞症严重程度的影响

目的探讨年龄增长对非高危肺血栓栓塞症(PTE)严重程度的影响。方法回顾性分析非高危PTE患者临床、实验室检查、影像学和超声心动图资料,134例非高危PTE患者根据年龄被分为18～59岁组34例、60～69岁组36例、70～79岁组31例和80～95岁组33例。结果显示老年人群中女性的比例随着年龄的增长而增加,肺动脉收缩压(SPAP)和不完全或完全右束支阻滞(RBBB)、右心功能不全(RVD)和中危PTE发生率随着年龄的增长而显著增加(均P0.05),多元回归分析显示中危PTE和年龄、性别、窦性心动过速明显相关(P0.05)。结论老年是中危PTE的危险因素,在急性PTE危险分层时也需要考虑到年龄因素。     

hs-CRP、TPI联合HEART评分系统在急性心源性胸痛中的应用及对主要不良心血管事件的预测价值

目的探讨超敏-C反应蛋白(hs-CRP)、肌钙蛋白I(TPI)联合HEART评分系统在急性心源性胸痛中的应用及对主要不良心血管事件(MACE)的预测价值。方法选择194例急性胸痛患者依据胸痛病因分为急性心源性胸痛组(n=108)和急性非心源性胸痛组(n=86),比较各组hs-CRP、TPI联合HEART评分,并按照HEART评分对急性心源性胸痛患者进行危险度分层(分为高危组、中危组、低危组),记录随访3个月MACE发生情况。结果急性心源性胸痛组hs-CRP、TPI及HEART评分高于急性非心源性胸痛组(P0.05),急性心肌梗死患者的hs-CRP、TPI及HEART评分高于心绞痛患者(P0.05)。急性心源性胸痛高危组患者中hs-CRP、TPI及HEART评分高于中危组及低危组,中危组患者的hs-CRP、TPI及HEART评分高于低危组(P0.05)。急性心源性胸痛高危组MACE总发生率高于中危组,中危组MACE总发生率高于低危组(P0.05)。有MACE者的hs-CRP、TPI及HEART评分高于无MACE者(P0.05)。hs-CRP、TPI、HEART评分、hs-CRP+TPI+HEART评分对急性心源性胸痛MACE预测的ROC曲线下面积分别为0.626、0.764、0.709、0.866。结论 hs-CRP、TPI联合HEART评分系统有利于急性心源性胸痛的定性诊断和危险分层,且对患者短期内MACE的发生有较高的预测价值。     

KAMIR危险评分在非ST段抬高型心肌梗死冠状动脉病变程度评估应用研究

目的探讨KAMIR危险评分在非ST段抬高型心肌梗死(NSTEMI)患者冠状动脉病变程度评估中的作用。方法应用KAMIR评分模型对同济大学附属第十人民医院2015—2016年收治的112例NSTEMI患者进行危险度评分,并依据分值将患者区分为低危组、中危组及高危组;记录各组患者冠脉造影结果,以Gensini法对患者造影图像进行积分,并分析KAMIR危险评分与冠状动脉病变血管数量及Gensini积分结果的相关性。结果 KAMIR评分结果为高危组的患者中,三支病变发生率显著高于低危及中危组患者,其冠状动脉图像Gensini积分亦显著高于低危及中危组患者。结论 KAMIR危险评分能够反映NSTEMI患者冠状动脉病变严重程度,可用于NSTEMI患者冠脉病变的早期评估。     

不同预后评分系统对老年NSTE-ACS患者远期预后的评估价值

目的探索grace评分和syntax评分对老年非ST段抬高急性冠状动脉综合征(NSTE-ACS)患者远期预后的评估价值。方法老年NSTE-ACS患者400例,随访时间16~24个月,完成随访392例,其中药物治疗组205例,置入支架组162例,冠脉搭桥术组25例。各组有计算grace评分和syntax评分,根据评分情况分为低危组、中危组和高危组。Pearson法分析grace和syntax评分的相关性;Kaplan-Meier法进行生存分析;Cox比例风险回归模型进行各因素分析;通过ROC曲线下面积比较预测准确性。结果 grace评分与syntax评分之间呈正相关(r=0.562,P<0.01)。grace评分得出的高危、中危、低危组患者心血管事件发生率依次降低(P<0.01)。syntax得出的高危组和中危组患者心血管事件发生率明显高于低危组(P<0.05),但高危与中危组之间差异无统计学意义(P>0.05)。grace评分和syntax评分对老年NSTE-ACS患者远期预后均有重要的评估价值。对grace评分、syntax评分和两者联合评分行ROC曲线分析显示,两者均对老年NSTE-ACS患者远期心血管事件风险有良好的预测价值,但在95%CI有明显重叠。结论 grace和syntax评分存在相关性,均对老年NSTE-ACS患者远期预后有重要预测价值,两者联用可在一定程度上提升预测准确性。grace评分适合对老年NSTE-ACS患者远预后进行危险程度分层。     

非ST段抬高急性冠脉综合征患者血清单核细胞/高密度脂蛋白比值与GRACE评分和SYNTAX评分相关性

目的探讨血清单核细胞/高密度脂蛋白(HDL)比值(MHR)与非ST段抬高急性冠脉综合征(NSTE-ACS)患者全球急性冠状动脉事件注册(GRACE)评分和SYNTAX评分的关系。方法纳入2018年因胸痛在心血管内科住院治疗,并行冠状动脉造影检查证实为NSTE-ACS患者236例。根据患者入院时GRACE评分,将患者分为GRACE评分低危、中危和高危组。入院后抽取患者的血常规及血脂生化检查,比较三组之间的MHR值,采用多因素Logistic回归分析MHR值与GRACE评分的关系。对所有患者进行冠状动脉造影检查,根据患者的冠状动脉病变特点,采用SYNTAX评分,将患者分为SYNTAX评分低危、中危及高危组,比较三组之间的MHR值。结果与低危及中危组相比,GRACE评分高危组患者的MHR水平明显升高(P0.05)。MHR与GRACE评分呈线性正相关(r=0.783,P0.05),多因素Logistic回归分析显示高MHR值是GRACE评分高危的独立预测因子。SYNTAX评分高危组患者的MHR值与中危组及低危组相比无明显差异(P0.05)。结论高MHR水平与NSTE-ACS患者GRACE评分的危险分组独立且显著相关,有助于判断NSTE-ACS患者的危险分层及短期预后。     

椎动脉优势对老年后循环短暂性脑缺血发作患者近期预后的分析

目的研究椎动脉优势对老年后循环短暂性脑缺血发作(TIA)患者近期预后的影响。方法前瞻性选择老年后循环TIA患者108例,其中椎动脉优势70例,非椎动脉优势38例,根据ABCD2评分脑梗死危险分层分为低危组31例,中危组65例,高危组12例,比较各组椎动脉磁共振血管成像、临床资料ABCD2评分,7d内脑梗死发生率。结果 108例TIA患者7d内进展为脑梗死者31例(28.7%)。中危组和高危组7d内脑梗死发生率明显高于低危组(30.8%,66.7%vs 9.7%,P<0.05,P<0.01),高危组7d内脑梗死发生率明显高于中危组(P<0.05);椎动脉优势患者7d内脑梗死发生率较非椎动脉优势患者明显增高(35.7%vs 15.8%,P<0.05);ABCD2评分<4分中,椎动脉优势与非椎动脉优势患者7d内发生脑梗死比较,无显著差异(P>0.05);ABCD2评分≥4分中,椎动脉优势患者7d内发生脑梗死较非椎动脉优势患者增高(47.9%vs 17.2%,P<0.05)。结论椎动脉优势为导致后循环TIA后脑梗死的危险因素之一;ABCD2评分中高危患者椎动脉优势的风险尤为明显。     

Unusual pulmonary embolism: septic pulmonary embolism and amniotic fluid embolism.

BACKGROUND: Septic and amniotic fluid emboli are rare sources of pulmonary embolism (PE), so the present study sought to elucidate the background of these cases. METHODS AND RESULTS: A total of 11,367 PE cases were identified from 396,982 postmortem examinations. The incidence of septic PE was 247 (2.2%) of the total. The origin of infection was found in 85.6% of the cases. Fungal embolus was detected more often than bacterial embolus. The most frequently detected fungus was aspergillus (20.8%). The primary disease associated with fungal embolus was leukemia (43.2%). The incidence of PE cases associated with pregnancy and/or delivery was 89 (0.8%) of the total PE cases. Among them, amniotic fluid embolism was found in 33 (73.3%) of 45 PE cases with vaginal delivery, and in 7 (21.2%) of 33 PE cases with cesarean delivery (p<0.0001). CONCLUSION: Fungal embolus was more frequent than bacterial embolus, and leukemia was most frequent as the primary disease in cases of fungal embolus. The main cause of PE in cesarean section cases was thrombotic embolism, and the main cause in vaginal delivery cases was amniotic fluid embolism.     

急性肺栓塞

急性肺栓塞（acute pulmonary embolism,APE）的临床表现范围从休克（shock）或持续性低血压（sustained hypotension）到轻度呼吸困难（dyspnea）。肺栓塞（pulmonary embolism）甚至有可能是无症状的,并且是在基于其他目的而实施的影像学操作中被诊断出来。     

Peripartum pulmonary embolism

Pregnancy is an example of Virchow's triad predisposing to the development of venous thromboembolism (VTE). Specific risk factors for antepartum and postpartum VTE have been identified. The diagnosis of pulmonary embolism in pregnancy is complicated by the physiologic changes of pregnancy as well as physicians' apprehension about ordering radiologic studies during pregnancy because of concerns with fetal well-being. Therapy for VTE is complicated by pregnancy physiology affecting medication pharmacokinetics and bioavailability, and the unpredictable occurrence of labor during therapeutic anticoagulation.     

Imaging pulmonary embolism

The diagnostic performance of computed tomography images of pulmonary embolism is directly related to the acquisition parameters. Any physician evaluating these scans must have proper knowledge of the acquisition, injection, reconstruction, and radiation parameters. Cardiac gating and morphological and functional image processing should be understood since they are now routine techniques particularly important for preoperative assessment of chronic thromboembolism. Elementary knowledge of the imaging techniques reduces the risk of diagnostic limitations. Understanding these techniques does not require any particularly advanced knowledge of physics, data processing or technology, but is necessary to chose the appropriate technical facilities and equipment adapted for diagnostic purposes. While specific training is not a prerequisite, interpretation of an angioscan of the pulmonary vessels does require precise knowledge of the pulmonary anatomy in addition to the technical knowledge mentioned above. Proper analysis may reach the 4th and 5th generation vessels. Different analysis methods have been developed which take into account the technical parameters and avoid the need for serial images. Each slice can then be analyzed within an acquisition Volume. Differential diagnosis is also very technique-dependent, minimally operator-dependent but highly machine-dependent. Differential diagnosis becomes less and less a problem with advancing equipment. Sufficient knowledge of the physiological and pathogenic basis is relatively easy to retain.     

Acute pulmonary embolism

Deep vein thrombosis (DVT) and, therefore, pulmonary embolism (PE) are often preventable. Because of the lack of specificity of symptoms and signs, DVT and PE are frequently clinically unsuspected, leading to substantial diagnostic and therapeutic delays and resulting in considerable morbidity and mortality. Furthermore, prophylaxis continues to be dramatically underused. The incidence of venous thromboembolism is high in hospitalized patients, and both surgical as well as medical patients are at risk.     

Postoperative pulmonary embolism

Post-operative thrombo-embolic disease remains a frequent occurrence in spite of advances in their prophylaxis. Evaluation of 60 case-reports of this disease which often includes peripheral manifestations and always pulmonary manifestations, enables to specify the role of the procedure itself (mostly orthopaedic surgery 60%), pelvic surgery 20%, the chronology of events (possibility of early embolism between D1 and D3 and usual occurrence of manifestations between D8 and D18, and the importance of the background, whether investigated or not: deficiencies in anti-thrombin III, protein C and S: 4 cases. The diagnosis is based on clinical signs (non-specific) and the laboratory tests, especially scintigraphy (screening) and angiography, absolutely necessary for the diagnosis and evaluation of the amputation coefficient (Miller index). With a diagnosis of pulmonary embolism, it is always necessary to look for a proximal venous thrombosis. The treatment, calls for heparin (quite seldom), thrombolytics (Urokinase, Plasminogen in our experience), the indication of which must take into consideration the delays and the nature of the previous procedure, and finally surgery (massive forms where thrombolytics are contraindicated). The thrombo-embolic manifestations with thrombogenic thrombopenia secondary to heparin are quite frequent, in a surgical environment (10 cases) and difficult to treat.