Department of Cardiology and Pulmonology, Georg August University of Göttingen, Göttingen, Germany.
Thromb Haemost. 2010 May;103(5):877-83. doi: 10.1160/TH10-01-0005. Epub 2010 Mar 9.
Patients with high-risk pulmonary embolism (PE), i.e. those with shock or hypotension at presentation, are at high risk of in-hospital death, particularly during the first hours after admission. A meta-analysis of trials which included haemodynamically compromised patients indicated that thrombolytic treatment significantly reduces the rate of in-hospital death or PE recurrence. Therefore, thrombolysis should be administered to patients with high-risk PE unless there are absolute contraindications to its use. Uncontrolled data further suggest that thrombolysis may be a safe and effective alternative to surgery in patients with PE and free-floating thrombi in the right heart. On the other hand, normotensive patients generally have a favourable short-term prognosis if heparin anticoagulation is instituted promptly, and they are thus considered to have non-high-risk PE. Generally, the bleeding risk of thrombolysis appears to outweigh the clinical benefits of this treatment in patients without haemodynamic compromise. However, within the group of normotensive patients with PE, some may have evidence of right ventricular dysfunction on echocardiography or computed tomography, or of myocardial injury based on elevated cardiac biomarkers (troponin I or T, heart-type fatty acid-binding protein). These patients have an intermediate risk of an adverse outcome in the acute phase of PE. Existing data suggest that selected patients with intermediate-risk PE may benefit from early thrombolytic treatment, particularly if they have a low bleeding risk. However, controversy will continue to surround the optimal treatment for this group until the results of a large ongoing thrombolysis trial are available in a few years.
高危肺栓塞（PE）患者，即出现休克或低血压的患者，住院期间死亡风险较高，尤其是在入院后最初几小时内。一项纳入血流动力学不稳定患者的试验的荟萃分析表明，溶栓治疗可显著降低住院期间死亡率或 PE 复发率。因此，除非有溶栓治疗的绝对禁忌证，否则应给予高危 PE 患者溶栓治疗。此外，不受控制的数据进一步表明，在右心游离血栓的 PE 患者中，溶栓治疗可能是手术的一种安全有效的替代方法。另一方面，如果及时给予肝素抗凝治疗，血压正常的患者一般有良好的短期预后，因此被认为是非高危 PE。一般来说，在没有血流动力学障碍的患者中，溶栓治疗的出血风险似乎超过了这种治疗的临床获益。然而，在 PE 血压正常的患者中，一些患者可能在超声心动图或计算机断层扫描上有右心室功能障碍的证据，或基于升高的心脏生物标志物（肌钙蛋白 I 或 T、心脏型脂肪酸结合蛋白）有心肌损伤的证据。这些患者在 PE 的急性阶段有不良结局的中度风险。现有数据表明，有选择的中危 PE 患者可能受益于早期溶栓治疗，特别是如果他们出血风险较低。然而，在几年后，一项大型正在进行的溶栓试验的结果公布之前，围绕这一人群的最佳治疗方案仍将存在争议。
