Respiratory Department and Medicine Department, Ramón y Cajal Hospital and Alcalá de Henares University, IRYCIS, Madrid, Spain.
Br J Haematol. 2010 Dec;151(5):415-24. doi: 10.1111/j.1365-2141.2010.08406.x. Epub 2010 Oct 19.
Treatment guidelines recommend strong consideration of thrombolysis in patients with acute symptomatic pulmonary embolism (PE) that present with arterial hypotension or shock because of the high risk of death in this setting. For haemodynamically stable patients with PE, the categorization of risk for subgroups may assist with decision-making regarding PE therapy. Clinical models [e.g. Pulmonary Embolism Severity Index (PESI)] may accurately identify those at low risk of overall death in the first 3 months after the diagnosis of PE, and such patients might benefit from an abbreviated hospital stay or outpatient therapy. Though some evidence suggests that a subset of high-risk normotensive patients with PE may have a reasonable risk to benefit ratio for thrombolytic therapy, single markers of right ventricular dysfunction (e.g. echocardiography, spiral computed tomography, or brain natriuretic peptide testing) and myocardial injury (e.g. cardiac troponin T or I testing) have an insufficient positive predictive value for PE-specific mortality to drive decision-making toward such therapy. Recommendations for outpatient treatment or thrombolytic therapy for patients with PE necessitate further development of prognostic models and conduct of clinical trials that assess various treatment strategies.
治疗指南建议对出现动脉低血压或休克的急性有症状肺栓塞 (PE) 患者强烈考虑溶栓治疗，因为在这种情况下死亡风险很高。对于血流动力学稳定的 PE 患者，亚组风险分类可能有助于决策 PE 治疗。临床模型[例如，肺栓塞严重指数 (PESI)]可能能够准确识别出在 PE 诊断后 3 个月内总体死亡风险低的患者，这些患者可能受益于缩短住院时间或门诊治疗。尽管有一些证据表明，PE 中具有一定风险的正常血压高风险患者可能具有合理的溶栓治疗获益风险比，但右心室功能障碍的单一标志物（例如超声心动图、螺旋 CT 或脑钠肽检测）和心肌损伤（例如肌钙蛋白 T 或 I 检测）对 PE 特异性死亡率的阳性预测值不足，无法推动此类治疗的决策。对于 PE 患者的门诊治疗或溶栓治疗建议，需要进一步开发预后模型并开展临床试验，评估各种治疗策略。
