Berman A R
Division of Pulmonary Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA.
Clin Geriatr Med. 2001 Feb;17(1):107-30. doi: 10.1016/s0749-0690(05)70109-9.
The elderly are at increased risk for pulmonary embolism because of both the conditions common to this age group, and the immobility that often accompanies them. Whether aging alone represents a hypercoagulable state is unclear. The incidence of pulmonary embolism rises with age, however, as does pulmonary embolism mortality. The diagnosis of pulmonary embolism is difficult and frequently missed because elderly patients and their physicians may attribute nonspecific symptoms to underlying cardiopulmonary disease or to age itself. Routine laboratory examinations are also nonspecific. Lower extremity studies to diagnose DVT should always be pursued because a positive study results in identical treatment, without the need for further testing. D-dimer concentrations are useful when low, but are commonly elevated in the elderly because of other comorbid conditions. Lung scanning remains the most common initial study to diagnose pulmonary embolism, although spiral CT is as sensitive and specific. Pulmonary angiography should always be considered when the initial studies are nondiagnostic and clinical suspicion is high, and this test is well tolerated in the elderly. The role of newer diagnostic techniques, such as MR imaging, cannot be determined until well-designed outcomes trials are completed. Prophylaxis with appropriate pharmacologic agents or mechanical measures should be administered not only to patients undergoing hip or knee reconstruction surgery, but to all bed-ridden elderly medical and general surgery patients. Treatment for pulmonary embolism with anticoagulation reduces the mortality rate and should be administered in all elderly patients without contraindications. In addition, thrombolysis should be considered for all hemodynamically unstable patients with pulmonary embolism, regardless of age. Vena caval filters are warranted when anticoagulation is contraindicated, although evidence of the long-term benefit of these devices is lacking. At present, pulmonary embolism is underdiagnosed and undertreated in the elderly. By heightening awareness of this diagnosis and its appropriate management in this age group, considerable morbidity and mortality may be avoided.
由于该年龄组常见的疾病以及常常伴随的活动不便，老年人发生肺栓塞的风险增加。仅衰老本身是否代表一种高凝状态尚不清楚。然而，肺栓塞的发病率和死亡率均随年龄增长而上升。肺栓塞的诊断困难且常常被漏诊，因为老年患者及其医生可能将非特异性症状归因于潜在的心肺疾病或年龄本身。常规实验室检查也缺乏特异性。应始终进行下肢检查以诊断深静脉血栓形成，因为检查结果阳性会导致相同的治疗，无需进一步检测。D - 二聚体浓度低时有用，但由于其他合并症，在老年人中通常会升高。肺部扫描仍然是诊断肺栓塞最常用的初始检查，尽管螺旋CT同样敏感和特异。当初始检查无法确诊且临床怀疑度高时，应始终考虑肺血管造影，而且该检查在老年人中耐受性良好。在完成精心设计的疗效试验之前，无法确定诸如磁共振成像等更新的诊断技术的作用。不仅应对接受髋部或膝部重建手术的患者，而且应对所有卧床的老年内科和普通外科患者采取适当的药物或机械措施进行预防。用抗凝剂治疗肺栓塞可降低死亡率，应在所有无禁忌证的老年患者中使用。此外，对于所有血流动力学不稳定的肺栓塞患者，无论年龄大小，均应考虑溶栓治疗。当抗凝禁忌时，有必要放置腔静脉滤器，尽管缺乏这些装置长期益处的确切证据。目前，老年人肺栓塞的诊断不足且治疗不充分。通过提高对该年龄组这一诊断及其适当管理的认识，可避免相当多的发病和死亡情况。
