den Exter Paul L, van der Hulle Tom, Klok Frederikus A, Huisman Menno V
Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
Thromb Res. 2014 May;133 Suppl 2:S10-6. doi: 10.1016/S0049-3848(14)50002-3.
The diagnostic management of acute pulmonary embolism (PE) is complicated by its heterogeneous clinical presentation. Current diagnostic algorithms, combining clinical probability estimation with D-dimer testing and imaging tests, are very safe to exclude PE, although at costs of high numbers of CT-examinations. In view of cost- and time-saving as well as safety issues, several attempts have recently been undertaken to reduce the number of required imaging tests. Especially the age-adjusted D-dimer threshold has greatly improved the potential for non-invasive exclusion of PE. Once the diagnosis of PE is established, immediate initiation of anticoagulant therapy is of vital importance. A new generation of direct oral anticoagulants, which overcomes the main disadvantages of conventional vitamin-K antagonists, has recently emerged. Risk stratification of hemodynamically stable PE patients with use of clinical decision rules, cardiac biomarkers or imaging tests, aids physicians in determining the most appropriate treatment approach for the individual patient. This is essential to differentiate patients at low risk of adverse outcome, who may be safely treated at home, from intermediate-risk patients, who require closer monitoring and for whom recent studies have evaluated the efficacy and safety of systemic thrombolytic therapy. This article reviews recent advances and challenges that remain in the diagnostic work-up and initial management of acute, clinically stable PE.
急性肺栓塞（PE）的临床表现具有异质性，这使得其诊断管理变得复杂。当前的诊断算法将临床概率评估与D - 二聚体检测及影像学检查相结合，虽然以大量CT检查为代价，但在排除PE方面非常安全。鉴于节省成本和时间以及安全性问题，最近已经进行了几次尝试以减少所需的影像学检查数量。特别是年龄调整后的D - 二聚体阈值极大地提高了无创排除PE的可能性。一旦确诊PE，立即启动抗凝治疗至关重要。新一代直接口服抗凝剂克服了传统维生素K拮抗剂的主要缺点，最近已出现。使用临床决策规则、心脏生物标志物或影像学检查对血流动力学稳定的PE患者进行风险分层，有助于医生为个体患者确定最合适的治疗方法。这对于区分低不良结局风险（可在家中安全治疗）的患者与中度风险患者至关重要，对于中度风险患者需要密切监测，并且最近的研究已经评估了全身溶栓治疗的疗效和安全性。本文综述了急性临床稳定PE的诊断检查和初始管理方面的最新进展和仍然存在的挑战。
