Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Cardiovascular Division, Boston, MA 02115, USA.
Lancet. 2012 May 12;379(9828):1835-46. doi: 10.1016/S0140-6736(11)61904-1. Epub 2012 Apr 10.
Pulmonary embolism is the third most common cause of death from cardiovascular disease after heart attack and stroke. Sequelae occurring after venous thromboembolism include chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Venous thromboembolism and atherothrombosis share common risk factors and the common pathophysiological characteristics of inflammation, hypercoagulability, and endothelial injury. Clinical probability assessment helps to identify patients with low clinical probability for whom the diagnosis of venous thromboembolism can be excluded solely with a negative result from a plasma D-dimer test. The diagnosis is usually confirmed with compression ultrasound showing deep vein thrombosis or with chest CT showing pulmonary embolism. Most patients with venous thromboembolism will respond to anticoagulation, which is the foundation of treatment. Patients with pulmonary embolism should undergo risk stratification to establish whether they will benefit from the addition of advanced treatment, such as thrombolysis or embolectomy. Several novel oral anticoagulant drugs are in development. These drugs, which could replace vitamin K antagonists and heparins in many patients, are prescribed in fixed doses and do not need any coagulation monitoring in the laboratory. Although rigorous clinical trials have reported the effectiveness and safety of pharmacological prevention with low, fixed doses of anticoagulant drugs, prophylaxis remains underused in patients admitted to hospital at moderate risk and high risk for venous thromboembolism. In this Seminar, we discuss pulmonary embolism and deep vein thrombosis of the legs.
肺栓塞是心血管疾病死亡的第三大常见原因,仅次于心脏病发作和中风。静脉血栓栓塞后的后遗症包括慢性血栓栓塞性肺动脉高压和血栓后综合征。静脉血栓栓塞和动脉血栓形成有共同的危险因素和共同的病理生理特征,包括炎症、高凝状态和内皮损伤。临床概率评估有助于识别临床可能性低的患者,对于这些患者,静脉血栓栓塞的诊断可以仅通过阴性的血浆 D-二聚体检测排除。诊断通常通过显示深静脉血栓形成的压缩超声或显示肺栓塞的胸部 CT 来确认。大多数静脉血栓栓塞患者将对抗凝治疗有反应,抗凝治疗是治疗的基础。肺栓塞患者应进行风险分层,以确定他们是否受益于更高级的治疗,如溶栓或取栓。几种新型口服抗凝药物正在开发中。这些药物可以替代许多患者的维生素 K 拮抗剂和肝素,以固定剂量开处方,不需要在实验室进行任何凝血监测。尽管严格的临床试验报告了低、固定剂量抗凝药物的药理学预防的有效性和安全性,但在静脉血栓栓塞风险中度和高度的住院患者中,预防的使用仍然不足。在本次研讨会上,我们将讨论肺栓塞和腿部深静脉血栓形成。