血压正常伴右心功能不全的急性肺栓塞患者临床分析

目的分析探讨血压正常伴右心功能不全（RVD）的急性肺栓塞（APE）患者的临床特点,以提高APE的诊治水平。方法回顾性分析天津医科大学总医院2009年1月至2012年1月确诊的130例血压正常的APE住院患者临床资料。经超声心动图检查发现伴RVD患者41例（RVD组）,不伴RVD患者89例（非RVD组）,对两组患者的临床特点、高危因素、诊断及治疗进行对比分析。结果 RVD组患者的临床症状和体征中,晕厥（34.1%比7.8%）、心动过速（41.4%比21.3%）、P2亢进（46.3%比25.8%）、颈静脉充盈（12.1%比1.1%）、发绀（26.8%比8.9%）的发生率均高于非RVD组患者（P〈0.05）。螺旋CT肺血管造影（CTPA）提示RVD组患者血栓栓塞累及近端肺动脉发生率（58.3%比8.3%）和肺叶肺动脉发生率（77.8%比51.2%）均高于非RVD组患者（P〈0.001,P〈0.05）。RVD组患者中13例给予溶栓加序贯抗凝治疗,28例给予单纯抗凝治疗。溶栓或抗凝治疗后组内临床指标心率、PaCO2、肺泡动脉氧分压差（AaDO2）、肺动脉收缩压（PASP）、三尖瓣反流压差（TRPG）]均有明显改善（P〈0.001）。但溶栓治疗患者治疗费用、小出血发生率均大于单纯抗凝治疗患者（P〈0.05）,治疗后AaDO2、PASP、TRPG均小于单纯抗凝治疗患者（P〈0.05）。结论对于CTPA提示中央型肺动脉栓塞和/或出现晕厥、心动过速等临床症状和体征的APE患者,需要及时明确有无RVD。对无恶化风险血压正常伴RVD的APE患者,采取抗凝治疗可以获得较高的疗效费用效益比。

Clinical Analysis of Patients with Acute Pulmonary Embolism,Normal Blood Pressure,and Right Ventricular Dysfunction

Objective To analyze the clinical features of patients with acute pulmonary embolism （APE） with normal blood pressure and right ventricular dysfunction. Methods 130 hospitalized patients with normotensive APE between January 2009 and January 2012 were retrospectively analyzed. The patients underwent transthoracic echocardiography to determine if they were complicated with RVD. The clinical features,risk factors, diagnosis, and treatment were analyzed and compared between the normotensive APE patients with or without RVD. Results 41 normotensive APE patients with RVD were as RVD group,and other 89 patients without RVD were as non-RVD group. The incidences of syncope （34. 1% vs. 7.8% ） , tachycardia（41.4% vs. 21.3% ）, P2 hyperthyroidism （ 46. 3% vs. 25.8% ）, jugular vein filling （ 12. 1% vs. 1.1% ） ,and cyanosis （26. 8% vs. 8. 9% ） were all significantly higher in the RVD group than those in the non-RVD group （ P 〈 0. 05 ）. Computed tomography pulmonary angiography （CTPA） revealed that the incidences of thromboembolism involving proximal pulmonary artery （ 58. 3% vs. 8.3% ） and thromboembolism involving lobar pulmonary （77. 8% vs. 51.2% ） were also higher in the RVD group （P 〈 0.001,P = 0.025 ）. In the RVD group, the patients were assigned to received thrombolysis plus anticoagulation therapy, or anticoagulation therapy alone. The clinical indicators （heart rate,PaC02, AaDO2, SPAP, TRPG） were all statistically improved after thrombolysis or anticoagulation treatment （P 〈0. 001 ）.But compared with the patients who underwent anticoagulation therapy alone, the cost of treatment and the incidence of minor bleeding were significantly higher, and the levels of AaD02, SPAP and TRPG were statistically lower in the patients with thrombolysis plus anticoagulation therapy. Conclusions For APE patients with central pulmonary embolism demonstrated by CTPA, syncope, and tachycardia, transthoracic echocardiograph should be performed as early as possible to confirm RVD diagnosis. For normotensive APE patients with RVD, anticoagulant treatment can achieve higher efficacy of cost- effectiveness ratio.