Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser K D, Rauber K, Iversen S, Redecker M, Kienast J
St. Josefs-Hospital, Wiesbaden, Germany.
J Am Coll Cardiol. 1997 Nov 1;30(5):1165-71. doi: 10.1016/s0735-1097(97)00319-7.
The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism.
The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated.
The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies.
Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%).
Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.
本研究调查了急性大面积肺栓塞的当前管理策略以及临床病程。
急性肺栓塞患者出现明显或即将发生的右心衰竭时的临床结局尚未得到充分阐明。
204个参与中心共纳入了1001例连续患者。纳入标准基于就诊时的临床表现以及心电图、超声心动图、核素成像和心导管检查的结果。
超声心动图是最常进行的诊断程序（74%）。79%临床稳定的患者进行了肺扫描或肺血管造影，但就诊时出现循环衰竭的患者中进行这些检查的频率要低得多（32%，p<0.001）。478例患者（48%）接受了溶栓药物治疗，尽管常有禁忌证（478例中的193例[40%]）。临床不稳定患者初始溶栓的频率显著高于血压正常的患者（57%对22%，p<0.001）。总体住院死亡率在稳定患者组中为8.1%，在出现心源性休克的患者中为25%，在需要心肺复苏的患者中为65%。92例患者（9.2%）报告发生了大出血，但脑出血不常见（0.5%）。最后，172例患者（17%）发生了复发性肺栓塞。
急性大面积肺栓塞的当前管理策略在很大程度上取决于就诊时血流动力学不稳定的程度。在存在严重血流动力学损害的情况下，医生通常依赖床旁超声心动图的结果并进行溶栓治疗，而不寻求核素成像或血管造影研究中进一步的诊断确定性。
