作者投稿
专家审稿
编辑办公
邮件订阅
RSS
-
摘要: 溶栓治疗是急性肺栓塞患者病情危重时挽救生命的重要治疗措施。虽然荟萃分析显示急性肺栓塞患者可从溶栓治疗中获益, 但在中危肺栓塞患者中给予溶栓, 由于出血风险的升高而未能降低死亡率。目前指南推荐在合并心搏骤停、梗阻性休克或持续性低血压的高危肺栓塞患者中给予溶栓治疗。溶栓治疗最主要的风险在于增加出血发生率, 尤其是颅内出血的发生率, 其亦是限制溶栓治疗广泛应用的主要原因。重组组织型纤溶酶原激活剂是目前应用最为广泛的溶栓药物, 疗效优于尿激酶和链激酶。一些减量溶栓研究获得了比较正面的结果, 但仍需进一步扩大研究规模加以验证。超声辅助导管溶栓是目前研究最多的局部溶栓技术, 在某些特定患者中可尝试应用。
-
关键词:
- 肺栓塞 /
- 溶栓治疗 /
- 重组组织型纤溶酶原激活剂
Abstract: Thrombolysis is an important treatment in critical patients with acute pulmonary embolism (PE). Although meta-analysis has shown that acute PE patients benefit from thrombolysis, the mortality is not reduced when thrombolysis is applied in patients with PE of intermediate risk due to the increased bleeding risk. Guidelines recommend that thrombolysis should be applied in high-risk PE with cardiac arrest, obstructive shock, or persistent hypotension. The most important risk of thrombolysis is bleeding, especially cranial bleeding, which restricts the wide use of thrombolysis. Recombinant tissue-type plasminogen activator is the most widely used thrombolytic agent, which is superior to urokinase and streptokinase. Some studies on reduced-dose thrombolysis achieved advantageous results, but more large-scale studies are needed. Ultrasound-assisted thrombolysis is a widely studied catheter-directed thrombolytic technique, and can be applied in some specific patients.利益冲突 无 -
表 1 急性肺栓塞溶栓药物、方案和禁忌证[3]
药物 方案 禁忌症 rt-PA： 100 mg，2 h内输注；0.6 mg/kg; 快速方案：15 min内输注(最大剂量50 mg)* 绝对禁忌证：出血性卒中史或原因不明的卒中史；缺血性卒中(前6个月内)；中枢神经系统肿瘤；严重创伤、手术或头部损伤(前3周内)；出血性素质；活动性出血 链激酶 负荷剂量250 000 IU，30 min内输注，后续100 000 IU/h，输注12~24 h；快速方案：150万IU，2 h内输注 相对禁忌证：短暂性脑缺血发作(前6个月内)；口服抗凝药；妊娠或产后1周内；穿刺部位无法压迫；创伤性心肺复苏；难治性高血压；重度肝病；感染性心内膜炎；活动性消化性溃疡 尿激酶 IU/(kg·h)，输注12~24 h；快速方案：300万IU，2 h内输注 rt-PA：重组组织型纤溶酶原激活剂；*此方案并未得到官方认可，但有时可用于血流动力学极度不稳时，比如心搏骤停 
下载: 导出CSV
-
[1] Wendelboe AM, Raskob GE. Global Burden of Thrombosis:Epidemiologic Aspects[J]. Circ Res, 2016, 118:1340-1347. doi: 10.1161/CIRCRESAHA.115.306841 [2] Raskob GE, Angchaisuksiri P, Blanco AN, et al. Thrombosis:a major contributor to global disease burden[J]. Arterioscler Thromb Vasc Biol, 2014, 34:2363-2371. doi: 10.1161/ATVBAHA.114.304488 [3] Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)[J]. Eur Heart J, 2019, 54. pii:1901647. https://erj.ersjournals.com/content/early/2019/08/29/13993003.01647-2019 [4] Keller K, Hobohm L, Ebner M, et al. Trends in thrombolytic treatment and outcomes of acute pulmonary embolism in Germany[J]. Eur Heart J, 2020, 41:522-529. https://academic.oup.com/eurheartj/article/41/4/522/5490731 [5] de Miguel-Diez J, Jimenez-Garcia R, Jimenez D, et al. Trends in hospital admissions for pulmonary embolism in Spain from 2002 to 2011[J]. Eur Respir J, 2014, 44:942-950. doi: 10.1183/09031936.00194213 [6] Lehnert P, Lange T, Moller CH, et al. Acute Pulmonary Embolism in a National Danish Cohort:Increasing Incidence and Decreasing Mortality[J]. Thromb Haemost, 2018, 118:539-546. doi: 10.1160/TH17-08-0531 [7] Dalla-Volta S, Palla A, Santolicandro A, et al. PAIMS 2:alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen activator Italian multicenter study 2[J]. J Am Coll Cardiol, 1992, 20:520-526. doi: 10.1016/0735-1097(92)90002-5 [8] Tibbutt DA, Davies JA, Anderson JA, et al. Comparison by controlled clinical trial of streptokinase and heparin in treatment of life-threatening pulmonay embolism[J]. Br Med J, 1974, 1:343-347. doi: 10.1136/bmj.1.5904.343 [9] Goldhaber SZ, Haire WD, Feldstein ML, et al. Alteplase versus heparin in acute pulmonary embolism:randomised trial assessing right-ventricular function and pulmonary perfusion[J]. Lancet, 1993, 341:507-511. doi: 10.1016/0140-6736(93)90274-K [10] Konstantinides S, Tiede N, Geibel A, et al. Comparison of alteplase versus heparin for resolution of major pulmonary embolism.[J] Am J Cardiol, 1998, 82:966-970. doi: 10.1016/S0002-9149(98)00513-X [11] Marti C, John G, Konstantinides S, et al. Systemic thrombolytic therapy for acute pulmonary embolism:a systematic review and meta-analysis[J]. Eur Heart J, 2015, 36:605-614. doi: 10.1093/eurheartj/ehu218 [12] Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism[J]. N Engl J Med, 2014, 370:1402-1411. doi: 10.1056/NEJMoa1302097 [13] Konstantinides S, Geibel A, Heusel G, et al. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism[J]. N Engl J Med, 2002, 347:1143-1150. doi: 10.1056/NEJMoa021274 [14] Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease:CHEST Guideline and Expert Panel Report[J]. Chest, 2016, 149:315-352. doi: 10.1016/j.chest.2015.11.026 [15] Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes[J]. Eur Heart J, 2020, 41:407-477. doi: 10.1093/eurheartj/ehz425 [16] Daniels LB, Parker JA, Patel SR, et al. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism[J]. Am J Cardiol, 1997, 80:184-188. doi: 10.1016/S0002-9149(97)00315-9 [17] Kline JA, Nordenholz KE, Courtney DM, et al. Treatment of submassive pulmonary embolism with tenecteplase or placebo:cardiopulmonary outcomes at 3 months:multicenter double-blind, placebo-controlled randomized trial[J]. J Thromb Haemost, 2014, 12:459-468. doi: 10.1111/jth.12521 [18] Chatterjee S, Chakraborty A, Weinberg I, et al. Throm-bolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage:a meta-analysis[J]. JAMA, 2014, 311:2414-2421. doi: 10.1001/jama.2014.5990 [19] Sadiq I, Goldhaber SZ, Liu PY, et al. Risk factors for major bleeding in the SEATTLE Ⅱ trial[J]. Vasc Med, 2017, 22:44-50. doi: 10.1177/1358863X16676355 [20] Papanikolaou J, Spathoulas K, Makris D, et al. Thrombol-ysis for Massive Pulmonary Embolism in a Patient with Hemorrhagic Shock[J]. Am J Respir Crit Care Med, 2016, 194:e15-e16. doi: 10.1164/rccm.201605-1035IM [21] Urokinase-streptokinase embolism trial. Phase 2 results. A cooperative study[J]. JAMA, 1974, 229: 1606-1613. [22] Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease:Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J]. Chest, 2012, 141:e419S-e496S. doi: 10.1378/chest.11-2301 [23] Verstraete M. Third-generation thrombolytic drugs[J]. Am J Med, 2000, 109:52-58. doi: 10.1016/S0002-9343(00)00380-6 [24] Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism:the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)[J]. Eur Heart J, 2008, 29:2276-2315. doi: 10.1093/eurheartj/ehn310 [25] Sharifi M, Bay C, Skrocki L, et al. Moderate pulmonary embolism treated with thrombolysis (from the "MOPETT" Trial)[J]. Am J Cardiol, 2013, 111:273-277. doi: 10.1016/j.amjcard.2012.09.027 [26] Wang C, Zhai Z, Yang Y, et al. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism:a randomized, multicenter, controlled trial[J]. Chest, 2010, 137:254-262. doi: 10.1378/chest.09-0765 [27] Bajaj NS, Kalra R, Arora P, et al. Catheter-directed treatment for acute pulmonary embolism:Systematic review and single-arm meta-analyses[J]. Int J Cardiol, 2016, 225:128-139. doi: 10.1016/j.ijcard.2016.09.036 [28] Kucher N, Boekstegers P, Muller OJ, et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism.[J] Circulation, 2014, 129:479-486. doi: 10.1161/CIRCULATIONAHA.113.005544 -
点击查看大图
表(1)
计量
- 文章访问数: 385
- HTML全文浏览量: 41
- PDF下载量: 296
- 被引次数: 0
