Abunasser Jafar, Tejada John Patrick, Foley Raymond J
Pulmonary and Critical Care Medicine Division, University of Connecticut School of Medicine, Farmington, USA.
Conn Med. 2012 Jan;76(1):5-14.
Pulmonary embolism (PE), most commonly originating from thrombosis in the deep venous system of the lower extremities, remains a controversial area of medicine that frequently generates lively debate. Its clinical presentation varies from asymptomatic, incidentally detected pulmonary emboli to massive embolism resulting in sudden death. Despite the advances made in recent years, a number of fundamental questions remain unanswered regarding the pathogenesis, clinical presentation, diagnosis and treatment of this disease. The diagnosis of PE is confounded by a presentation that may be subtle, atypical, or obscured by a concomitant condition. Safe, minimally invasive techniques have been developed to improve the diagnostic accuracy of the clinical evaluation, and obviate the need to obtain pulmonary arteriography in all but a minority of patients. However, no single diagnostic test is sufficiently sensitive or specific for diagnosis in all patients. This dilemma has resulted in the development of numerous clinical scoring systems to stratify risk, pretest probability and help guide an appropriate diagnostic approach. Anticoagulation therapy with unfractionated heparin (UFH), low molecular weight heparin (LMWH), and Factor Xa inhibitors are the mainstay of therapy for acute PE. The choice of agent is influenced by disease severity, presence or absence of provokingfactors, patient comorbidities, and bleeding risk. These factors also determine whether measures such as thrombectomy, thrombolysis and vena cava filter placement may be employed as adjuncts to anticoagulation. Warfarin is the agent of choice for secondary prevention; newer agents such as direct thrombin and factor Xa inhibitors are emerging as safe and effective alternatives.
肺栓塞（PE）最常见于源自下肢深静脉系统的血栓形成，它仍然是医学上一个有争议的领域，经常引发激烈的辩论。其临床表现从无症状、偶然发现的肺栓塞到导致猝死的大面积栓塞不等。尽管近年来取得了进展，但关于这种疾病的发病机制、临床表现、诊断和治疗仍有许多基本问题未得到解答。PE的诊断因临床表现可能不明显、不典型或被伴随疾病掩盖而变得复杂。已经开发出安全、微创的技术来提高临床评估的诊断准确性，并且除少数患者外无需进行肺动脉造影。然而，没有一种单一的诊断测试对所有患者的诊断都具有足够的敏感性或特异性。这种困境导致了众多临床评分系统的发展，以分层风险、预测前概率并帮助指导适当的诊断方法。使用普通肝素（UFH）、低分子量肝素（LMWH）和Xa因子抑制剂进行抗凝治疗是急性PE治疗的主要手段。药物的选择受疾病严重程度、诱发因素的存在与否、患者合并症和出血风险的影响。这些因素还决定了诸如血栓切除术、溶栓和腔静脉滤器置入等措施是否可作为抗凝的辅助手段。华法林是二级预防的首选药物；新型药物如直接凝血酶和Xa因子抑制剂正作为安全有效的替代药物出现。
