急性肺血栓栓塞患者血清酶学及肌钙蛋白I的变化

目的观察急性肺血栓栓塞（PTE）患者血清酶学及肌钙蛋白Ⅰ（TnI）的变化，了解其与估测肺动脉收缩压、右心运动功能及预后的关系。方法519例PTE患者来自北京24家医院参与的国家“十五”科技攻关课题——肺栓塞规范化诊治方法的研究。根据2001年5月中华医学会呼吸病学分会制定的《肺血栓栓塞症的诊断与治疗指南（草案）》的诊断标准确定大面积、次大面积、非大面积肺栓塞患者。大面积、次大面积肺栓塞患者采用溶栓治疗，非大面积肺栓塞患者采用抗凝治疗。按中心随机方法将患者分组，应用尿激酶和重组组织型纤溶酶原激活剂及普通肝素和低分子肝素。结果（1）大面积肺栓塞患者治疗前血清丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）、肌酸激酶（CPK）、乳酸脱氢酶（LDH）水平（74±33）、（88±40）、（157±75）、（419±264）U／L]明显高于次大面积肺栓塞患者（52±21）、（43±18）、（75±30）、（284±176）U／L]和非大面积肺栓塞患者（38±13）、（35±11）、（78±24）、（239±178）U／L]；（2）非大面积肺栓塞患者应用普通肝素治疗7d后血清ALT（84±39）U／L]明显高于应用低分子肝素患者（67±26）U／L]；（3）519例患者中45例肺动脉收缩压≥80mmHg（1mmHg=0．133kPa），治疗前存在右心运动功能减弱169例，预后不良48例。大面积肺栓塞患者中17例（41．5％）AIJT升高，次大面积中76例（45．5％），非大面积中26例（54．5％）。大面积肺栓塞患者中24例（54．4％）LDH升高，次大面积中68例（40．2％），非大面积中15例（30．8％）；（4）39例血清TnI≥0．07μg／L的患者中右心功能减弱24例（63．3％），预后不良者8例（24．2％）。结论（1）急性PTE患者可出现血清ALT、ASF、CPK、LDH水平升高；（2）非大面积肺栓塞患者应用抗凝治疗，普通肝素较低分子肝素更易引起血清ALT升高；（3）血清ALT、LDH以及TnI的升高与PTE患者的肺动脉收缩压、右心运动功能及预后密切相关，其变化可能有助于对急性肺栓塞患者进行危险分层。

The changes of serum enzymes and cardiac troponin I in patients with acute pulmonary thromboembolism

OBJECTIVES: To investigate the changes of serum enzymes and cardiac troponin I (TnI) in patients with acute pulmonary thromboembolism (PTE). The relationships between these changes and the pulmonary artery pressure, the right ventricular function and the prognosis were evaluated. METHODS: This prospective multi-centre trial included 519 patients with confirmed PTE from 24 collaborating hospitals, with 54 cases of massive PTE, 195 sub-massive PTE and 270 non-massive PTE. Thrombolytic treatment with urokinase or recombinant tissue plasminogen activator (rt-PA) was administered for massive and sub-massive PTE patients; anti-coagulative therapy with unfractionated heparin or low molecular weight heparin was used for non-massive PTE. RESULTS: The values of serum ALT, AST, CPK and LDH before treatment in massive PTE (74 +/- 33), (88 +/- 40), (157 +/- 75), (419 +/- 264) U/L] were significantly higher than those in sub-massive (52 +/- 21), (43 +/- 18), (75 +/- 30), (284 +/- 176) U/L] and non-massive cases (38 +/- 13), (35 +/- 11), (78 +/- 24), (239 +/- 178) U/L] (P < 0.05). The value of serum ALT at day 7 (84 +/- 39 U/L) in the unfractionated heparin sub-group of the non-massive PTE was significantly higher than that (67 +/- 26 U/L) in the low molecular weight heparin sub-group (P = 0.045). Of the 45 cases with high pulmonary pressure > 80 mm Hg (1 mm Hg = 0.133 kPa), 24 (54.4%) cases showed high serum LDH (P = 0.032) and 17 (41.5%) high serum ALT (P = 0.049). Of the 169 cases with right ventricular dysfunction, 68 (40.2%) cases showed high serum LDH (P = 0.049) and 76 (45.5%) high serum ALT (P = 0.037). Of the 48 cases with poor prognosis, 15 (30.8%) cases showed high serum LDH (P = 0.039) and 26 (54.5%) high serum ALT (P = 0.022). Of the 39 cases with TnI > or = 0.07 microg/L, 24 (63.3%) cases were complicated with decreased right ventricular function (P < 0.01) and 8 (24.2%) with poor prognosis (P = 0.034). CONCLUSIONS: The values of serum ALT, AST, CPK, LDH and TnI are increased in acute PTE. Unfractionated heparin results in higher levels of ALT than lower molecular weight heparin. The increase of serum ALT, LDH and TnI is correlated with pulmonary artery pressure, right ventricular function and the prognosis of the PTE. These changes may be useful in the risk stratification of PTE patients.