Struttura Operativa Dipartimentale Malattie Aterotrombotiche, Azienda Ospedaliero-Universitaria di Careggi, Italy.
Curr Opin Pulm Med. 2011 Sep;17(5):392-7. doi: 10.1097/MCP.0b013e328349289a.
Pulmonary embolism is the most serious complication of venous thromboembolism, with an elevated case/fatality rate. Patients who survived a first episode of pulmonary embolism should be evaluated for the risk of recurrence and of chronic thromboembolic pulmonary hypertension (CTEPH).
The risk of recurrence is higher in patients with unprovoked pulmonary embolism than in those with transient risk factors. Persistent risk factors, such as active cancer and antiphospholipid antibodies, are associated with high risk of recurrence. Recently, elevated D-dimer levels after discontinuation of therapy have been identified as a risk factor for recurrence. CTEPH is characterized by intravascular organization of emboli and occurs in 0.5-1% of cases. Some patients with CTEPH have impaired fibrinolysis, likely due to a structural abnormality of fibrin or fibrin clot. Echocardiography often reveals signs of pulmonary hypertension. This should be confirmed by direct measurement of pulmonary artery pressures at right heart catheterization.
CTEPH patients should receive life-long anticoagulation for preventing recurrent pulmonary embolism. Pulmonary endarterectomy is the treatment of choice for patients with proximal pulmonary vascular occlusion. Patients with predominantly distal pulmonary vascular occlusion are candidates for pharmacological treatment. All patients with unprovoked pulmonary embolism should be evaluated for long-term anticoagulation.
肺栓塞是静脉血栓栓塞症最严重的并发症，其病死率较高。首次发生肺栓塞的患者应评估其复发风险和慢性血栓栓塞性肺动脉高压（CTEPH）的风险。
与有短暂风险因素的患者相比，无诱因肺栓塞患者的复发风险更高。持续性风险因素，如活动性癌症和抗磷脂抗体，与高复发风险相关。最近，治疗停止后 D-二聚体水平升高被确定为复发的一个风险因素。CTEPH 的特征是血管内血栓形成，其在 0.5-1%的病例中发生。一些 CTEPH 患者的纤维蛋白溶解受损，可能是由于纤维蛋白或纤维蛋白凝块的结构异常所致。超声心动图常显示肺动脉高压的迹象。这应通过右心导管检查直接测量肺动脉压力来证实。
CTEPH 患者应终身接受抗凝治疗以预防肺栓塞复发。肺血管内膜切除术是近端肺血管阻塞患者的治疗选择。主要为远端肺血管阻塞的患者适合药物治疗。所有无诱因肺栓塞患者均应评估长期抗凝治疗的必要性。
