Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
Semin Respir Crit Care Med. 2017 Feb;38(1):56-65. doi: 10.1055/s-0036-1597560. Epub 2017 Feb 16.
Pulmonary embolism (PE) is a major cause of both acute and long-term morbidity for a large number of patients worldwide, and massive PE is frequently fatal. Right ventricular (RV) dysfunction is a key determinant of prognosis in the acute phase of PE. Patients with clinically overt RV failure, that is, with cardiogenic shock or persistent hypotension at presentation (acute high-risk PE), are clearly in need of immediate reperfusion treatment with systemic thrombolysis or, alternatively, surgical or catheter-directed techniques. On the other hand, within the large group of patients presenting without hemodynamic instability, the bleeding risk of full-dose intravenous thrombolytic treatment has been shown to outweigh its benefits, even if they present with evidence of both RV dysfunction and myocardial injury. Thus, current guidelines agree in proposing a strategy of effective anticoagulation and "watchful waiting" (with initial hemodynamic monitoring notably over the first 48-72 hours) in intermediate-risk PE, with an indication for rescue thrombolysis if signs of hemodynamic decompensation appear. Recently published trials suggest that catheter-directed, ultrasound-assisted, low-dose local fibrinolysis may provide an effective and particularly safe treatment option for some of these patients. Ongoing or planned studies are expected to resolve the controversy on the efficacy and safety or reduced-dose systemic thrombolysis and to address the possible impact of thrombolytic therapy on long-term outcomes after acute PE.
肺栓塞（PE）是全球大量患者急性和长期发病的主要原因，而且大块肺栓塞常常是致命的。右心室（RV）功能障碍是 PE 急性期预后的关键决定因素。临床上明显 RV 衰竭的患者，即出现心源性休克或就诊时持续低血压（急性高危 PE），显然需要立即进行溶栓治疗，如全身溶栓治疗，或者选择手术或导管引导的技术。另一方面，在无血流动力学不稳定的大量患者中，全剂量静脉溶栓治疗的出血风险已被证明超过其益处，即使他们同时存在 RV 功能障碍和心肌损伤的证据。因此，目前的指南一致建议在中危 PE 中采用有效的抗凝和“密切观察”（特别是在最初的 48-72 小时内进行初始血流动力学监测）策略，如果出现血流动力学恶化的迹象，则进行溶栓治疗。最近发表的试验表明，导管引导的、超声辅助的、低剂量局部纤溶可能为这些患者中的一些人提供有效且特别安全的治疗选择。正在进行或计划进行的研究有望解决关于小剂量全身溶栓治疗的疗效和安全性或减少剂量全身溶栓治疗的争议，并解决溶栓治疗对急性 PE 后长期结局的可能影响。
