Daley Mitchell J, Murthy Manasa S, Peterson Evan J
University Medical Center Brackenridge, Seton Healthcare Family, Department of Pharmacy, Austin, USA.
Seton Medical Center Williamson, Seton Healthcare Family, Department of Pharmacy, Round Rock, TX, USA.
Ther Adv Drug Saf. 2015 Apr;6(2):57-66. doi: 10.1177/2042098615572333.
Acute pulmonary embolism represents a major complication of venous thromboembolism that is associated with high morbidity and mortality. Guidelines recommend the rapid initiation of anticoagulation and consideration of thrombolytic therapy in select patients, including those with hypotension or at high risk of developing hypotension. Evaluation for thrombolytic therapy should only be considered after assessment of contraindications and risk for major bleeding. The objective of this perspective article is to evaluate the bleeding risk associated with systemic thrombolytic therapy in the management of acute pulmonary embolism and discuss strategies to minimize this risk. Risk stratification of acute pulmonary embolism will be discussed to identify patient populations that warrant specific consideration of risk for major bleeding with thrombolytic therapy. In addition, the incidence, patient-specific risk factors, and pharmacologic characteristics, including concurrent anticoagulation and thrombolytic therapy, will be evaluated in the context of risk for major hemorrhage. Finally, supporting evidence for strategies to minimize risk of hemorrhage, including evaluation of contraindications, weight adjusted dosing, infusion strategy and catheter-directed thrombolytic administration will be evaluated. Despite published guidelines and review articles, select aspects to thrombolytic therapy for the management of pulmonary embolism remain controversial and under recognized, including risk of major hemorrhage. When making decisions about the role of thrombolytic therapy in pulmonary embolism, clinicians must be knowledgeable about the associated risks of thrombolytic therapy and individually evaluate patient risk factors prior to determining appropriate candidacy for thrombolytic therapy. For patients considered to be at high risk of major bleeding, strategies to minimize risk should be considered, including weight-adjusted doses and catheter directed therapy. Additional research is needed specific to the acute pulmonary embolism setting to validate risk factors and strategies to minimize major hemorrhage.
急性肺栓塞是静脉血栓栓塞的一种主要并发症，与高发病率和死亡率相关。指南建议迅速启动抗凝治疗，并考虑对特定患者进行溶栓治疗，包括那些有低血压或有发生低血压高风险的患者。仅在评估禁忌证和大出血风险后，才应考虑进行溶栓治疗评估。这篇观点文章的目的是评估全身溶栓治疗在急性肺栓塞管理中相关的出血风险，并讨论将该风险降至最低的策略。将讨论急性肺栓塞的风险分层，以确定那些需要特别考虑溶栓治疗大出血风险的患者群体。此外，还将在大出血风险的背景下评估发病率、患者特异性风险因素以及药物特性，包括同时进行的抗凝和溶栓治疗。最后，将评估降低出血风险策略的支持证据，包括禁忌证评估、体重调整剂量、输注策略和导管定向溶栓给药。尽管有已发表的指南和综述文章，但肺栓塞管理中溶栓治疗的某些方面仍存在争议且未得到充分认识，包括大出血风险。在决定溶栓治疗在肺栓塞中的作用时，临床医生必须了解溶栓治疗的相关风险，并在确定合适的溶栓治疗候选资格之前，单独评估患者的风险因素。对于被认为有大出血高风险的患者，应考虑将风险降至最低的策略，包括体重调整剂量和导管定向治疗。需要针对急性肺栓塞情况进行更多研究，以验证风险因素和将大出血降至最低的策略。
