Short-term Prognostic Factors of Thrombolytic Therapy for Acute Pulmonary Embolism: A Case-control Study
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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。
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关键词:
- 急性肺栓塞 /
- 溶栓治疗 /
- 重组组织型纤溶酶原激活剂 /
- 死亡风险 /
- 出血
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. -
主编:Deepak L. Bhatt
出版商:Elsevier
心脏导管和介入术自20世纪上半叶由德国外科医生福斯曼发明以来, 逐步发展和完善, 已经成为当代心脏病学的基石。该领域的技术已从简单的压力测量、描记曲线, 发展为心血管疾病明确诊断、完成治疗不可或缺的手段。很多风险高、创伤大的外科手术已被微创、低风险的介入治疗所取代,医疗经济效益比因此显著提高。如今,心血管介入领域的设备器材、诊疗程序和技术仍在日新月异地发展,如何不断更新和提高介入技术水平,面对不同患者作出最正确的介入临床决策,是心血管医师面临的极大挑战。本书由著名的心血管介入专家Bhatt博士负责组织编写,全面系统地介绍了心血管介入各个领域的最新诊断和治疗策略,以及相关介入技术的原理和要点。
本书分为7部分。第1部分介绍心脏介入治疗的指南、辅助药物和周边技术。第2部分则具体论述冠状动脉介入手术中的难点如无保护左主干病变、慢性完全闭塞病变、分叉病变、桥血管、支架内再狭窄、血栓病变等的处理,以及血管内成像技术的操作、应用和进展。第3部分是外周血管介入,分别阐述上下肢动脉、肾动脉、肠系膜动脉及胸腹主动脉瘤等病变处理技巧,此外还涉及了最新的肾动脉去交感神经术。第4部分脑血管介入术,分为颈、椎动脉和颅内动脉介入两部分。第5部分为静脉系统介入治疗,包括下肢深静脉血栓和肺栓塞的处理,慢性深静脉功能不全及血液透析动静脉瘘通路的处理。第6部分是结构性心脏病的介入诊疗,包括主动脉瓣成型术和经导管主动脉瓣置换术,经导管二尖瓣介入术,肥厚型心肌病、卵圆孔未闭、房间隔缺损及室间隔缺损的封堵,心内膜活检和心包穿刺及介入治疗。最后一部分简要介绍了其他先天性心脏病如主动脉缩窄、动静脉瘘畸形等的介入策略。
心脏介入学是一个操作性、可视性极强的学科,本书充分体现了这一特点。其包含431幅彩图和116个图表,直观、清晰地阐述了诊治流程和介入操作中的关键所在,相应网站上的视频和动画更方便于学习和知识更新。因此,作为Braunwald心脏病学伴侣系列丛书中的一本,本书不仅适用于从事心血管介入或接受心血管介入专科培训的医生,对放射科介入医生、心血管外科医生和经常与介入医生密切合作的其他心血管医生都有很好的参考作用,是一本不可多得的实用性极强的心血管介入参考书。
(北京协和医院心内科 郭潇潇)
(中国医学科学院图书馆 供 稿)
利益冲突 无 -
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 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 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 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 -
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