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急性肺栓塞溶栓治疗的短期预后影响因素:病例对照研究

乔优,  袁媛,  范俊平,  孙雪峰,  施举红

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文章导航 > 协和医学杂志  > 2020 >  11(2): 144-150
乔优, 袁媛, 范俊平, 孙雪峰, 施举红. 急性肺栓塞溶栓治疗的短期预后影响因素:病例对照研究[J]. 协和医学杂志, 2020, 11(2): 144-150. doi: 10.3969/j.issn.1674-9081.20180085
引用本文: 乔优, 袁媛, 范俊平, 孙雪峰, 施举红. 急性肺栓塞溶栓治疗的短期预后影响因素:病例对照研究[J]. 协和医学杂志, 2020, 11(2): 144-150. doi: 10.3969/j.issn.1674-9081.20180085
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You QIAO, Yuan YUAN, Jun-ping FAN, Xue-feng SUN, Ju-hong SHI. Short-term Prognostic Factors of Thrombolytic Therapy for Acute Pulmonary Embolism: A Case-control Study[J]. Medical Journal of Peking Union Medical College Hospital, 2020, 11(2): 144-150. doi: 10.3969/j.issn.1674-9081.20180085
Citation: You QIAO, Yuan YUAN, Jun-ping FAN, Xue-feng SUN, Ju-hong SHI. Short-term Prognostic Factors of Thrombolytic Therapy for Acute Pulmonary Embolism: A Case-control Study[J]. Medical Journal of Peking Union Medical College Hospital, 2020, 11(2): 144-150. doi: 10.3969/j.issn.1674-9081.20180085
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急性肺栓塞溶栓治疗的短期预后影响因素:病例对照研究

doi: 10.3969/j.issn.1674-9081.20180085

  • 中国医学科学院 北京协和医学院 北京协和医院呼吸与危重症医学科, 北京 100730

基金项目: 

十三五精准医学研究"肺血栓栓塞症诊疗规范及应用方案的精准化研究" 2016YF0905603

北京市级大学生科研创新项目"中国人华法林相关基因多态性与个体化精准用药研究" 2017zlgc0650

详细信息
    通讯作者:

    施举红 电话:010-69155028, E-mail:shijh@pumch.cn

  • 中图分类号: R563.5

Short-term Prognostic Factors of Thrombolytic Therapy for Acute Pulmonary Embolism: A Case-control Study

  • Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China

More Information
    Corresponding author: SHI Ju-hong Tel: 86-10-69155028, E-mail:shijh@pumch.cn

    摘要
  • 摘要:   目的  探究急性肺栓塞溶栓治疗患者的短期预后相关因素。  方法  回顾性收集2014年1月至2017年11月北京协和医院经计算机断层扫描肺血管造影或超声心动图确诊并接受重组组织型纤溶酶原激活剂溶栓治疗的急性肺栓塞患者的临床资料, 包括基础疾病、病程、临床特征、实验室检查、影像学表现、治疗及转归等, 结合简化版肺栓塞严重指数, 分析患者溶栓后7、14、30 d预后相关危险因素。  结果  共23例符合纳入和排除标准的患者入选本研究, 其中男性5例, 女性18例, 平均年龄(57.3±14.0)岁。16例患者存活(69.6%, 16/23), 7例死亡(30.4%, 7/23), 7 d病死率为26.1%(6/23), 14 d及30 d病死率均为30.4%(7/23)。与存活组相比, 死亡组患者sPESI更高[3(2, 3)比2(1, 2), P=0.008], 收缩压[(79.3±25.4)mm Hg比(108.7±18.1) mm Hg, P=0.005]、血小板计数[(135.1±58.3)×109/L比(223.2±89.4)×109/L, P=0.012]、血钙浓度[(1.9±0.2)mmol/L比(2.1±0.2)mmol/L, P=0.030]均更低, N端脑钠肽前体水平更高[6372(1637, 17 228)pg/ml比1166(343, 1821)pg/ml, P=0.035], 心肺复苏更常见(100%比12.5%, P=0.000)。单因素生存分析显示, 心率>110次/min(P=0.012)、收缩压 < 90 mm Hg(P=0.000)、进行心肺复苏(P=0.000)或N端脑钠钛前体水平>6000 pg/ml(P=0.001)的患者14 d生存率更低, 而无恶性肿瘤、无慢性心肺疾病、动脉血氧饱和度≥ 90%、血小板≥ 200×109/L或血钙≥ 2.00 mmol/L并不能显著改善14 d存活情况。  结论  在急性肺栓塞溶栓患者中, 低血压、心肺复苏、较高心率及N端脑钠肽前体水平可能预示着更高的短期死亡风险, 低血钙、低血小板能否作为短期死亡预测因子仍需进一步研究论证。
    Abstract:   Objective  This study aimed to identify the possible short-term risk factors associated with the mortality of patients with acute pulmonary embolism after thrombolytic therapy.  Methods  We retrospectively collected the patients with acute pulmonary embolism who were diagnosed by computed tomography pulmonary angiography (CTPA) or echocardiography (ECHO) and received thrombolytic therapy with recombinant tissue-type plasminogen activator (rt-PA) in Peking Union Medical College Hospital from January 2014 to November 2017. The collection of clinical data including comorbidities, course of the disease, clinical features, laboratory tests, imaging findings, simplified pulmonary embolism severity index (sPESI), treatment, outcomes, etc. were used to analyze the prognostic factors of disease 7 days, 14 days and 30 days after thrombolytic therapy.  Results  A total of 23 patients, 5 males and 18 females, were included in the study with an average age of (57.3 ±14.0) years. Sixteen patients survived (69.6%, 16/23) and 7 died (30.4%, 7/23); the 7-day, 14-day and 30-day mortality was 26.1% (6/23), and 30.4%(7/23), 30.4%(7/23), respectively. Compared to the survival group, patients in the death group had higher sPESI[3(2, 3)vs 2(1, 2), P=0.008], lower systolic pressure[(79.3±25.4)mm Hg vs (108.7±18.1)mm Hg, P=0.005], less platelets[(135.1±58.3)×109/L vs (223.2±89.4)×109/L, P=0.012], lower calcium concentration[(1.9±0.2)mmol/L vs(2.1±0.2)mmol/L, P=0.030], higher N-terminal pro-B-type natriuretic peptide (NT-proBNP)[6372(1637, 17 228)pg/ml vs 1166(343, 1821)pg/ml, P=0.035], and more frequent cardiopulmonary resuscitation (100% vs 12.5%, P=0.000). Survival analysis indicated that patients who had a heart rate>110 beats/min (P=0.012), systolic blood pressure < 90 mm Hg(P=0.000), cardiopulmonary resuscitation(P=0.000), or NT-proBNP >6000 pg/ml (P=0.001) had a lower 14-day survival rate. Factors such as the absence of malignant tumors or chronic cardiopulmonary disease, arterial oxygen saturation ≥ 90%, platelets ≥ 200×109/L, and blood calcium ≥ 2.00 mmol/L made no difference in the improvement of 14-day survival.  Conclusions  In patients with acute pulmonary embolism after thrombolytic therapy, hypotension, cardiopulmonary resuscitation, elevated heart rate and NT-proBNP may indicate a higher risk of short-term mortality. Whether hypocalcemia and thrombocytopenia can be used as short-term prognostic factors requires further researches.
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  • 表  1  急性肺栓塞溶栓治疗患者生存组与死亡组临床特征

    指标 生存组
    (n=16)    		 死亡组
    (n=7)    		 P值
    男性[n(%)] 4(25.0) 1(14.3) 1.000
    sPESI[M(P25, P75)] 2(1，2) 3(2，3) 0.008
    年龄(x±s，岁) 57.7±14.0 56.6±15.2 0.865
    合并恶性肿瘤[n(%)] 4(25.0) 1(14.3) 1.000
    合并慢性心肺疾病
       [n(%)]    		 6(37.5) 2(28.6) 1.000
    心率(x±s，次/min) 94.1±22.3 105.9±38.0 0.467
    收缩压(x±s，mm Hg) 108.7±18.1 79.3±25.4 0.005
    动脉血氧饱和度
       [M(P25, P75), %]    		 92(81，99) 83.0(76，88) 0.054
    心肺复苏[n(%)] 2(12.5) 7(100.0) 0.000
    病程[M(P25, P75)，d] 4.0(1.5, 7.0) 4.0(0.08, 5.5) 0.597
    sPESI:简化版肺栓塞严重指数
    下载: 导出CSV

    表  2  急性肺栓塞溶栓治疗患者生存组与死亡组实验室检查结果比较

    指标 生存组(n=16) 死亡组(n=7) P值
    白细胞(x±s，×109/L) 12.1±5.3 11.3±3.5 0.711
    中性粒细胞百分比(x±s, ，%) 72.8±13.5 81.3±15.0 0.195
    血红蛋白(x±s，g/L) 127.9±20.5 56.6±15.2 0.439
    血小板(x±s，×109/L)[n(%)] 223.2±89.4 135.1±58.3 0.012
    肌酸激酶[M(P25, P75)，U/L] 54(28, 88) 94(29, 115) 0.898
    肌钙蛋白Ⅰ[M(P25, P75), μg/L] 0.110(0.062, 0.282) 0.210(0.054, 1.547) 0.055
    N端脑钠肽前体[M(P25, P75)，pg/ml] 1166(343, 1821) 6372(1637, 17 228) 0.035
    D二聚体[M(P25, P75)，mg/L] 6.66(2.23, 17.97) 25.95(10.13, 31.99) 0.243
    pH(x±s, ) 7.00±1.60 7.17±0.31 0.804
    钙(x±s，mmol/L) 2.1±0.2 1.9±0.2 0.030
    钾(x±s，mmol/L) 4.0±0.5 3.8±0.7 0.552
    氯(x±s，mmol/L) 103.8±4.3 104.0±6.5 0.935
    谷丙转氨酶[M(P25, P75)，U/L] 40(20, 65) 55(16, 97) 0.754
    白蛋白(x±s，g/L) 34.3±5.3 28.9±7.0 0.055
    肌酐(x±s，μmol/L) 79.1±26.0 105.1±35.2 0.060
    下载: 导出CSV

    表  3  急性肺栓塞溶栓治疗患者生存组与死亡组溶栓情况及出血事件

    指标 生存组(n=16) 死亡组(n=7) P值
    起病至溶栓时间[M(P25, P75)，d] 4(1.5，7) 4(0.08，5.5) 0.597
    溶栓剂量[M(P25, P75)，mg] 50(50, 50) 50(50, 62.5) 0.042
    溶栓后出血事件[n(%)] 7(43.8) 1(14.3) 0.345
    大出血事件[n(%)] 2(12.5) 1(14.3) 1.000
    下载: 导出CSV

    表  4  急性肺栓塞溶栓治疗后短期预后影响因素的单因素分析

    指标 最佳截断值 P值
    伴发恶性肿瘤 是/否 0.646
    伴发慢性心肺疾病 是/否 0.787
    心率(次/min) ≤110/＞110 0.012
    收缩压(mm Hg) ＜90/≥90 0.000
      ＜100/≥100 0.066
    动脉血氧饱和度(%) ＜90/≥90 0.089
    心肺复苏 是/否 0.000
    N端脑钠肽前体(pg/ml) ≤6000/＞6000 0.001
    血小板(109/L) ＜200/≥200 0.073
    血钙(mmol/L) ＜2.00/≥2.00 0.066
    下载: 导出CSV
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