Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
J Intern Med. 2016 Jan;279(1):16-29. doi: 10.1111/joim.12404. Epub 2015 Aug 19.
Due to the nonspecific symptoms of the condition, a diagnosis of acute pulmonary embolism (PE) is frequently considered. However, PE will only be confirmed in 10-20% of patients. Because the imaging test of choice, computed tomography pulmonary angiography (CTPA), is costly and associated with radiation exposure and other complications, a validated diagnostic algorithm consisting of a clinical decision rule and D-dimer test should be used to safely exclude PE in 20-30% of patients without the need for CTPA. Recently, the age-adjusted D-dimer threshold has been validated, and this has increased the proportion of patients at older age in whom PE can be excluded without CTPA. Initial therapeutic management of PE depends on the risk of short-term PE-related mortality. Haemodynamically unstable patients should be closely monitored and receive thrombolytic therapy unless contraindicated because of an unacceptably high bleeding risk, whereas patients with low-risk PE may be safely discharged early from hospital or receive only outpatient treatment. The PESI score and Hestia decision rule are available to select patients in whom early discharge or outpatient treatment will be safe, although the safety of these strategies should be confirmed in additional studies. Standard PE therapy consists of low molecular weight heparin (LMWH) followed by vitamin K antagonists (VKAs). Recently, several nonvitamin K-dependent oral anticoagulants have been shown to be as effective as LMWH/VKAs, and maybe safer. Determining the optimal duration of treatment for a first unprovoked PE remains a challenge, although clinical prediction rules for estimating the risk of recurrence of venous thromboembolism and anticoagulation-associated haemorrhage are under investigation. Using these prediction rules may lead to both more standardized and more individualized long-term treatment of PE.
由于该病的症状不具特异性，急性肺栓塞（PE）的诊断常被考虑。然而，只有 10-20%的患者会被确诊为 PE。由于首选的影像学检查——计算机断层肺动脉造影（CTPA）——既昂贵，又与辐射暴露和其他并发症相关，因此应使用经验证的诊断算法，包括临床决策规则和 D-二聚体检测，以安全地排除 20-30%无需 CTPA 检查的患者中的 PE。最近，年龄调整后的 D-二聚体阈值已经得到验证，这增加了可以在无需 CTPA 检查的情况下排除老年患者中 PE 的比例。PE 的初始治疗管理取决于短期与 PE 相关的死亡率风险。血流动力学不稳定的患者应密切监测并接受溶栓治疗，除非因无法接受的高出血风险而禁忌，而低危 PE 患者可早期安全出院或仅接受门诊治疗。PESI 评分和 Hestia 决策规则可用于选择可安全出院或门诊治疗的患者，但这些策略的安全性需要在额外的研究中加以证实。标准的 PE 治疗包括低分子肝素（LMWH），然后是维生素 K 拮抗剂（VKA）。最近，一些非维生素 K 依赖性口服抗凝剂已被证明与 LMWH/VKA 一样有效，而且可能更安全。确定首次无诱因 PE 的最佳治疗持续时间仍然是一个挑战，尽管用于估计静脉血栓栓塞复发风险和抗凝相关出血风险的临床预测规则正在研究中。使用这些预测规则可能会导致更标准化和更个体化的 PE 长期治疗。
