Barco Stefano, Konstantinides Stavros V
Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
Thromb Res. 2017 Mar;151 Suppl 1:S92-S96. doi: 10.1016/S0049-3848(17)30076-2.
The presence and severity of right ventricular (RV) dysfunction is a key determinant of prognosis in the acute phase of pulmonary embolism (PE). Risk-adapted treatment strategies continue to evolve, tailoring initial management to the clinical presentation and the functional status of the RV. Beyond pharmacological and, if necessary, mechanical circulatory support, systemic thrombolysis remains the mainstay of treatment for hemodynamically unstable patients; in contrast, it is not routinely recommended for intermediate-risk PE. Catheter-directed pharmacomechanical reperfusion treatment represents a promising option for minimizing bleeding risk; for reduced-dose intravenous thrombolysis, the data are still preliminary. Non-vitamin K-dependent oral anticoagulants, directly inhibiting factor Xa (rivaroxaban, apixaban, edoxaban) or thrombin (dabigatran), have simplified initial and long-term anticoagulation for PE while reducing major bleeding risk. Use of vena cava filters should be restricted to selected patients with absolute contraindications to anticoagulation, or PE recurrence despite adequately dosed anticoagulants.
右心室（RV）功能障碍的存在及其严重程度是肺栓塞（PE）急性期预后的关键决定因素。风险适应性治疗策略不断发展，根据临床表现和右心室功能状态调整初始治疗方案。除了药物治疗以及必要时的机械循环支持外，全身溶栓仍然是血流动力学不稳定患者的主要治疗方法；相比之下，对于中危PE患者，通常不推荐进行全身溶栓。导管导向的药物机械性再灌注治疗是降低出血风险的一种有前景的选择；对于小剂量静脉溶栓，数据仍属初步。非维生素K依赖的口服抗凝剂，直接抑制因子Xa（利伐沙班、阿哌沙班、依度沙班）或凝血酶（达比加群），简化了PE的初始和长期抗凝治疗，同时降低了大出血风险。腔静脉滤器的使用应仅限于有抗凝绝对禁忌证的特定患者，或尽管使用了足量抗凝剂仍发生PE复发的患者。
