解读2008欧洲心脏病学会急性肺血栓栓塞症诊断治疗指南(续完)

3 急性肺栓塞的溶栓治疗 随机试验已证实,溶栓治疗可迅速溶解血栓,缓解血栓栓塞造成的血管闭塞,改善血流动力学和心功能.多中心临床研究表明尿激酶和链激酶静脉滴注12～24小时疗效相同.与尿激酶以4400 IU/(kg·h)的速度静脉滴注12～24小时相比,100 mg重组组织型纤溶酶原激活剂(recombinant tissue plasminogen activator,rt-PA)静脉2小时输注可更快改善血流动力学,但尿激酶静脉滴注完毕后二者的溶栓效果无明显差异.     

组织型纤溶酶原激活剂治疗肺栓塞

组织型纤溶酶凉激活剂是一种作用较强的溶栓剂,对纤维蛋白有一定的选择性,能溶解肺栓塞患者的血栓,降低肺动脉压,改善右心室功能。与尿激酶相比,组织型纤溶酶原激活剂起效快,副作用小。     

急性肺血栓栓塞的溶栓治疗

急性肺血栓栓塞 (ＡＰＥ)的溶栓治疗始于 30年前。长期以来 ,人们一直在探求能够提高疗效、降低出血风险的药物和治疗方法。随着优质溶栓药物的开发及溶栓方案、给药途径的改进 ,ＡＰＥ的溶栓治疗已取得了长足的进展。现有溶栓剂主要有链激酶 (ＳＫ)、尿激酶 (ＵＫ)、重组组织型纤溶酶原激活剂 (ｒｔ -ＰＡ) ,均为纤溶酶原激活剂 ,是具有启动 -放大纤溶系统的有效药物。它通过激活纤溶酶原而溶解血栓 ,使其降解成可溶性肽类。目前新一代溶栓剂如 :重组组织型纤溶酶原激活剂ｔ -ＰＡ缺失突变体 (ｒ -ＰＡ)、ＴＮＫ -组织型纤溶酶原激活剂 (Ｔ…     

急性大面积肺栓塞的重组组织型纤溶酶原激活剂静脉溶栓治疗

本文报道１例急性肺栓塞采用~（９９ｍ）Ｔｃ－Ｐ３５７标测肺动脉内新鲜血栓，并进行肺动脉造影，显示大块新鲜血栓堵塞于左、右肺动脉干的急性大面积肺栓塞，肺动脉压中度升高。选用重组组织型纤溶酶原激活剂（ｒｔ－ＰＡ）进行静脉溶栓治疗。溶栓后再次行肺动脉造影，结果显示大块血栓基本溶解，部分肺动脉的小分支内仍有残余血栓，肺动脉压降至正常。本例表明，急性肺栓塞如能得到及时诊断和治疗，可迅速逆转大面积肺栓塞所致的血液动力学障碍，~（９９ｍ）Ｔｃ－Ｐ３５７是最先进的、准确的诊断急性肺栓塞的检测手段，ｒｔ－ＰＡ是一安全、有效的溶栓药物。     

重组组织型纤溶酶原激活剂治疗急性心肌梗死44例

1995年8月-2000年6月我科用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)44例,报告如下.     

重组组织型纤溶酶原激活剂静脉溶栓治疗缺血性卒中中国专家共识（2012版）

 重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator, rt PA）是目前治疗急性缺血性卒中（acute ischemic stroke, AIS）最有效的药物,时间窗内静脉rt PA溶栓是惟一被证实可以减少AIS生存患者残疾率的治疗方法。自2006年我国《临床应用重组组织型纤溶酶原激活剂静脉溶栓治疗缺血性卒中专家共识》发表以来,AIS静脉溶栓治疗取得很大的进展,因此有必要对专家共识进行更新。     

不同剂量重组组织型纤溶酶原激活剂溶栓治疗急性心肌梗死的疗效评价

目的比较50rag和100mg重组组织型纤溶酶原激活剂（rt—PA）溶栓治疗急性心肌梗死疗效的差别。方法入选78例急性心肌梗死患者,其中50mg组35例,100mg组43例。两组患者都常规应用阿司匹林和肝素等药物,分别静脉注射重组组织型纤溶酶原激活剂（rt—PA）50mg和100mg。比较两组患者溶栓后的冠状动脉开通率（根据临床判定）,发病30d左室射血分数和死亡率。结果冠状动脉开通率50mg组为77．1％（27例）,100mg组为81．4％（35例）;30d左室射血分数分别为（48．7±7．2）％,（50．0±7．6）％;30d病死率分别为5．7％（2例）,4．7％（2例）,两组间比较均无统计学意义。结论100mg和50mg重组组织型纤溶酶原激活剂（rt—PA）对于国人急性心肌梗死的溶栓疗效相似。     

重组组织型纤溶酶原激活剂静脉溶栓治疗急性心肌梗塞的临床观察（摘要）

重组组织型纤溶酶原激活剂静脉溶栓治疗急性心肌梗塞的临床观察（摘要）龙凤军，李兆文，潘永康，梁学众本研究试图就国人应用重组组织型纤溶酶原激活剂（ｒｔ－ＰＡ）静脉溶栓的疗效、副作用问题进行探讨。一、对象与方法１．病例选择：胸痛持续≥３０ｍｉｎ，经含硝酸甘...     

重组组织型纤溶酶原激活剂联合肝素治疗心肌梗死25例

目的观察重组组织型纤溶酶原激活剂(rt-PA)与尿激酶(UK)溶栓治疗急性心肌梗死(AMI)的临床疗效。方法将符合入选标准的61例AMI病人随机分为两组,rt-PA组先予爱通立8mg静脉输注,继之42mg在90min内静脉输注联合静脉肝素治疗。尿激酶组予尿激酶1.5×106U加入中生理盐水30min内滴完,分别观察溶栓2h的再通率。结果溶栓后2hrt-PA组临床再通率为88.0%,尿激酶组为63.9%,两组相比有统计学意义(P<0.05)。结论rt-PA是一种安全、有效的静脉溶栓药物。     

艾通立、链激酶和尿激酶静脉溶栓治疗与非溶栓治疗急性心肌梗死的疗效比较

静脉溶栓治疗已作为急性心肌梗死(心梗)的主要治疗手段之一。我们采用重组组织型纤溶酶原激活剂(rt-PA，艾通立)、链激酶、尿激酶对急性心梗进行静脉溶栓治疗，并与非溶栓组进行比较，探讨静脉溶栓治疗的重要性。     

Free floating right atrial thrombus leading to acute pulmonary embolism

The presence of right heart thrombi appears to increase the risk of mortality compared to the presence of pulmonary thromboemboli alone. The increased use of two-dimensional echocardiography has led to increased detection of these thromboemboli, particularly in patients with suspected or confirmed pulmonary emboli. The optimal management of the right heart thromboemboli remains unclear, but thrombolytic therapy with rt-PA appears to be rapidly effective in most patients resulting with complete resolution of the thrombus and improvement of pulmonary perfusion. Here, we present a case of free floating, worm-like thrombus in the right atrium which was lysed successfully by fibrinolytic therapy in a patient presenting with acute massive pulmonary embolism.     

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)     

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.     

尤瑞克林在组织型纤维蛋白酶原激活剂静脉溶栓治疗急性脑梗死中的应用

目的 初步评价尤瑞克林在重组组织型纤维蛋白酶原激活剂(rt-PA)静脉溶栓治疗急性缺血性脑梗死中的安全性和有效性.方法 采用随机、对照研究方法 ,入选患者按1:1随机分为对照组和试验组.对照组22例,仅给予rt-PA(0.9 mg/kg);试验组22例,rt-PA(0.9 mg/kg)溶栓后静脉滴注尤瑞克林(0.15 PNAU/d,连续7 d).主要安全性评价指标是溶栓24 h内症状性脑出血发生率,次要评价指标为患者神经功能缺损评分(NIHSS)、日常生活活动能力评分(BI). 结果 溶栓24 h内,试验组与对照组比较,脑出血率差异无统计学意义(4.6%对9.1%,X2=0.00,P>0.05),再梗死率有降低趋势(18.2%对31.8%,X2=1.091,P>0.05).溶栓治疗后1 d、21 d和90 d,试验组NIHSS评分显著低于对照组(t值分别为2.119、2.913、2.187,均P<0.05),试验组90 d BI评分显著高于对照组(t=2.39,P<0.05). 结论 在不增加出血风险的情况下,尤瑞克林提高rt-PA静脉溶栓治疗急性脑梗死的疗效.     

Reperfusion pulmonary edema after thrombolytic therapy of massive pulmonary embolism

We report here the occurrence of acute focal pulmonary edema after thrombolytic therapy for massive pulmonary embolism. Symptomatic pulmonary edema developed in a 75-yr-old man after streptokinase infusion for a massive pulmonary embolism. Repeat radiographic studies demonstrated that the edema occurred in an area of early reperfusion. Right heart catheterization showed pulmonary hypertension, and there was no clinical evidence of left ventricular failure. The edema spontaneously resolved during a second course of thrombolytic therapy that successfully lysed the remaining thrombus. We conclude that reperfusion pulmonary edema is a potential, albeit rare, complication of thrombolytic therapy for pulmonary embolism.     

29例急性肺栓塞临床观察及治疗研究

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２９例肺栓塞患者根据放射性核素肺灌注通气检查、选择性肺动脉造影或超声心动图确诊。对其中２３例肺栓塞患者行静脉溶栓加抗凝治疗２９例次;６例肝素抗凝治疗,以临床及核素检查评价其治疗效果。结果男性患者中以年轻超力型发病者较高,女性患者以更年期以后发病明显增高。院外误诊率高达７５．９％。临床上以呼吸困难为主要表现者多见;尿激酶或重组组织型纤溶酶原激活剂（ｒｔ－ＰＡ）溶栓２９例次,总有效率为６５．５％。根据本组有限病例观察溶栓效果与栓塞的面积未见差异,而与发病开始到溶栓治疗的时间密切相关（Ｐ＜０．０５）。肝素抗凝６例,１例显效,２例有效,３例无效。结论应提高对急性肺栓塞的警惕性,减少误诊率;尿激酶或ｒｔ－ＰＡ对急性肺栓塞溶栓抗凝治疗安全有效,溶栓时间越早越好;对有溶栓适应证的患者应首选溶栓治疗。     

Recombinant tissue-type plasminogen activator versus a novel dosing regimen of urokinase in acute pulmonary embolism: a randomized controlled multicenter trial.

Thrombolysis of acute pulmonary embolism can be accomplished more rapidly and safely with 100 mg of recombinant human tissue-type plasminogen activator (rt-PA) (Activase) than with a conventional dose of urokinase (Abbokinase) given as a 4,400-U/kg bolus dose, followed by 4,400 U/kg per h for 24 h. To determine the effects of a more concentrated urokinase dose administered over a shorter time course, this trial enrolled 90 patients with baseline perfusion lung scans and angiographically documented pulmonary embolism. They were randomized to receive either 100 mg/2 h of rt-PA or a novel dosing regimen of urokinase: 3 million U/2 h with the initial 1 million U given as a bolus injection over 10 min. Both drugs were delivered through a peripheral vein. To assess efficacy after initiation of therapy, repeat pulmonary angiograms at 2 h were performed in 87 patients and then graded in a blinded manner by a panel of six investigators. Of the 42 patients allocated to rt-PA therapy, 79% showed angiographic improvement at 2 h, compared with 67% of the 45 patients randomized to urokinase therapy (95% confidence interval for the difference in these proportions [rt-PA minus urokinase] is -6.6% to 30.4%; p = 0.11). The mean change in perfusion lung scans between baseline and 24 h was similar for both treatments. Three patients (two treated with rt-PA and one with urokinase) had an intracranial hemorrhage, which was fatal in one. The results indicate that a 2-h regimen of rt-PA and a new dosing regimen of urokinase exhibit similar efficacy and safety for treatment of acute pulmonary embolism.     

Rapid resolution of acute cor pulmonale with recombinant tissue plasminogen activator

A case of massive pulmonary embolism complicated by acute cor pulmonale and shock is presented. The IV administration of recombinant tissue-type plasminogen activator (rt-PA) was associated with prompt reversal of clinical, ECG, and nuclear radiographic findings. The role of thrombolytic therapy with rt-PA for massive pulmonary embolism associated with hemodynamic decompensation deserves further investigation.     

Intracerebral hemorrhage with thrombolytic therapy for acute pulmonary embolism

BackgroundIntracranial hemorrhage is one of the dreaded complications of thrombolytic therapy for acute pulmonary embolism. We identified patients with pulmonary embolism who may be at relatively high risk of intracerebral hemorrhage from those selected for thrombolytic therapy by their physicians and presumably thought to be of reasonable risk.MethodsThe number of patients discharged from short-stay hospitals in the United States from 1998 to 2008 with pulmonary embolism who received thrombolytic therapy and the proportion with intracerebral hemorrhage were determined from the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.ResultsFrom 1998 to 2008, 2,237,600 patients were discharged with a diagnosis of pulmonary embolism. Among patients who received thrombolytic therapy for pulmonary embolism, the prevalence of intracerebral hemorrhage was 430 of 49,500 (0.9%). The prevalence increased linearly with age more than 10 years. Intracerebral hemorrhage was less frequent in those with a primary diagnosis of pulmonary embolism (250/39,300 [0.6%]) than in those with a secondary diagnosis (180/10,300 [1.7%], P <.0001). The prevalence of intracerebral hemorrhage was lower in patients aged 65 years or less with no kidney disease (90/16,900 [0.5%]) than in patients aged more than 65 years or with kidney disease (290/20,900 [1.4%], P <.0001). The prevalence remained lower in those with a primary diagnosis (90/23,000 [0.4%] than in those with a secondary diagnosis (50/5700 [0.9%], P <.0001).ConclusionThe cause of intracerebral hemorrhage in patients with pulmonary embolism who receive thrombolytic therapy seems to be multifactorial and related to comorbidity and age.     

Free-floating thrombus in the right heart and pulmonary embolism

We describe the case of a woman with acute pulmonary embolism and free-floating thrombus in the right heart. The diagnosis was performed using transthoracic echocardiography. The patient received urgent intravenous thrombolytic therapy with tissue plasminogen activator and vasoactive agent. This observation emphasizes the echocardiographic monitoring during thrombolysis in acute pulmonary embolism, allowing to strictly assess cardiac chamber sizes.