Stein P D, Hull R D
Henry Ford Heart and Vascular Institute, Detroit.
Chest. 1994 Sep;106(3):727-30. doi: 10.1378/chest.106.3.727.
The purpose of this investigation was to assess the relative risks of antithrombotic treatment following pulmonary angiography vs no angiography in patients with acute pulmonary embolism (PE). Comparisons of risks of diagnosis and therapy were made among patients treated on the basis of a pulmonary angiographic diagnosis vs patients treated on the basis of a ventilation/perfusion (V/Q) scan combined with clinical assessment in the presence of a single negative test for deep venous thrombosis. Calculations of risks assumed major complications of pulmonary angiography equal to 1.3 percent, major bleeding with heparin equal to 4.9 percent (1.1 percent among patients with a low risk of bleeding and 10.8 percent among patients with a high risk of bleeding), and major bleeding with warfarin (international normalized ratio 2 to 3) equal to 1.7 percent. Among patients with a risk of major bleeding from heparin followed by warfarin of 6.6 percent, if the estimated probability of PE was greater than about 80 percent, fewer major complications of diagnosis and treatment would occur if treatment was initiated on the basis of the V/Q scan. If the probability of PE in such patients was less than 80 percent, fewer major complications of diagnosis and treatment would occur if the diagnosis was established by pulmonary angiography. Among patients with a high (12.5 percent) risk of major bleeding, it was shown to be safer to treat on the basis of an angiographic diagnosis if the estimated probability of PE was less than 90 percent. If the patients, however, were at low (2.8 percent) risk of major bleeding, fewer major complications would occur if angiography was reserved for patients with an estimated risk of PE less than about 50 percent. Serial studies of the leg veins may eliminate the need for angiography in such patients.
本研究的目的是评估急性肺栓塞（PE）患者在接受肺血管造影后进行抗血栓治疗与未进行血管造影相比的相对风险。在基于肺血管造影诊断进行治疗的患者与基于通气/灌注（V/Q）扫描并结合临床评估（在深静脉血栓形成单项检查结果为阴性的情况下）进行治疗的患者之间，对诊断和治疗风险进行了比较。风险计算假设肺血管造影的主要并发症发生率为1.3%，肝素导致的大出血发生率为4.9%（出血风险低的患者中为1.1%，出血风险高的患者中为10.8%），华法林（国际标准化比值为2至3）导致的大出血发生率为1.7%。在肝素治疗后使用华法林且大出血风险为6.6%的患者中，如果PE的估计概率大于约80%，那么基于V/Q扫描开始治疗时，诊断和治疗的主要并发症会更少。如果此类患者中PE的概率小于80%，那么通过肺血管造影进行诊断时，诊断和治疗的主要并发症会更少。在大出血风险高（12.5%）的患者中，如果PE的估计概率小于90%，基于血管造影诊断进行治疗被证明更安全。然而，如果患者大出血风险低（2.8%），对于估计PE风险小于约50%的患者保留血管造影检查，那么主要并发症会更少。对腿部静脉进行系列研究可能会消除此类患者进行血管造影的必要性。
