Consultant Hematologist, Department of Haematology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India, Corresponding Author.
Senior Consultant, Department of Pulmonary and Critical Care, KD Hospital, Ahmedabad, Gujarat, India.
J Assoc Physicians India. 2024 Nov;72(11):80-91. doi: 10.59556/japi.72.0737.
Pulmonary embolism (PE) is an important cause of morbidity and mortalityespecially among hospitalized patients. Although the exact epidemiology of PE is not known in India, several studies have shown that it is missed and mismanaged not infrequently, leading to significant cardiovascular morbidity and mortality. Indian consensus for the diagnosis and treatment of acute PE has been previously published. Recent findings from studies including data available from Indian studies have expanded our knowledge with respect to the optimal diagnosis, assessment, and treatment of patients with PE and have been integrated into this review article. Acute PE patients should be stratified according to early mortality risk. Clinical measures, right ventricular (RV) dysfunction markers, and myocardial injury should be used to determine risk stratification. The clinical prediction criteria [pulmonary embolism severity index (PESI) and Hestia criteria] should be routinely used in emergency departments. Investigations, such as D-dimer, electrocardiogram (ECG), chest X-ray, routine labs, N-terminal pro B-type natriuretic peptide/brain natriuretic peptide (NT-ProBNP/BNP), troponin I or troponin T, heart-type fatty acid binding protein (H-FABP), echocardiography, lower limb compression ultrasonography (CUS), computed tomographic-pulmonary angiography (CTPA), ventilation-perfusion scintigraphy (V/Q scan), and pulmonary angiography should be appropriately selected in suspected cases of PE as per risk stratification. The main treatment in medical management of acute PE comprises anticoagulants and thrombolytics. According to current guidelines, oral anticoagulants such as warfarin are recommended to be started at the time of diagnosis together with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux (all grade IA). Owing to their predictable bioavailability and pharmacokinetics, novel oral anticoagulants (NOACs) can be given at fixed doses without routine laboratory monitoring. Recurrence is not uncommon on cessation of therapy, and hence long-term anticoagulation may be required in selected cases. Strong positive evidence is available for the use of thrombolytics in the management of acute PE.
肺栓塞（PE）是发病率和死亡率的重要原因，尤其是在住院患者中。虽然印度的 PE 确切流行病学情况尚不清楚，但有几项研究表明，PE 经常被漏诊和处理不当，导致严重的心血管发病率和死亡率。印度曾发表过急性 PE 的诊断和治疗共识。最近的研究结果，包括来自印度研究的数据，扩展了我们对 PE 患者最佳诊断、评估和治疗的认识，并已纳入这篇综述文章。急性 PE 患者应根据早期死亡率风险进行分层。应使用临床指标、右心室（RV）功能障碍标志物和心肌损伤来确定风险分层。临床预测标准[肺栓塞严重指数（PESI）和 Hestia 标准]应在急诊科常规使用。应根据风险分层适当选择检查，如 D-二聚体、心电图（ECG）、胸部 X 线、常规实验室检查、N-末端 pro B 型利钠肽/脑利钠肽（NT-ProBNP/BNP）、肌钙蛋白 I 或肌钙蛋白 T、心脏型脂肪酸结合蛋白（H-FABP）、超声心动图、下肢压缩超声（CUS）、计算机断层扫描-肺动脉造影（CTPA）、通气-灌注闪烁扫描（V/Q 扫描）和肺动脉造影，以诊断疑似 PE。急性 PE 药物治疗的主要治疗方法包括抗凝剂和溶栓剂。根据目前的指南，建议在诊断时同时使用华法林等口服抗凝剂与普通肝素（UFH）、低分子量肝素（LMWH）或磺达肝癸钠（均为 IA 级）。由于其可预测的生物利用度和药代动力学，新型口服抗凝剂（NOACs）可固定剂量给药，无需常规实验室监测。停药后复发并不少见，因此在某些情况下可能需要长期抗凝。有强有力的证据表明溶栓剂可用于急性 PE 的治疗。
