肺栓塞指南解读

1、12(1) Initial risk stratification(2) Thrombolytic treatment(3) New oral anticoagulants(4) Chronic thromboembolic pulmonary hypertension3difficult to determine： remain asymptomatic diagnosis may be an incidental finding sudden death4 over 317 000 deaths were related to VTE in six countries of the Eur

2、opean Union (with a total population of 454.4 million) in 2004: 34% presented with sudden fatal PE 59% were deaths resulting from PE that remained undiagnosed during life 7%of the patients who died early were correctly diagnosed with PE before death. (Cohen AT, Venousthromboembolism (VTE) in Europe.

3、 The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98(4):756764.)5l surgery l traumal immobilizationl pregnancyl oral contraceptive use l hormone replacement therapyl cancerl obesityl infection and central venous lines6uAcute PE interferes with circulation and gas

4、exchangeuRight ventricular (RV) failure is considered the primary cause of death in severe PE7Replace “massive PE sub-massive PE submassive PE”8Clinical presentation non-specific 91011the negative predictive value is highthe positive predictive value is low（cancer, inflammation, bleeding, trauma, su

5、rgery and necrosis）age-adjusted cut-offs (age x 10 mg/L above 50 years) increasing specificity from 3446% and sensitivity above 97%（Schouten HJ. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism:systematic review and me

6、ta-analysis. BMJ 2013;346:f2492）121314gold standardrarely performed now used to guide percutaneous catheter-directed treatment of acute PE.Thrombi as small as 12 mm within the sub-segmental arteries can be visualized by DSA15 Lung scintigraphy Magnetic resonance angiography Echocardiography：RV press

7、ure overload and dysfunction Compression venous ultrasonography:DVT16(BNP) or N-terminal (NT)-proBNPtroponin I or -Tserum creatinine levels and glomerular filtration rateH-FABP17181920Haemodynamic support: 1 aggressive volume expansion is of no benefit and may even worsen RVfunction 2 use of vasopre

8、ssors is necessary 1)Norepinephrine:hypotensive patients 2)dobutamine,dopamine:low cardiac index, and normal BP 3)Epinephrine(combines the beneficial norepinephrine and dobutamine) 4)inhalation of nitric oxide 5)levosimendan21respiratory support:administration of oxygen:reversed hypoxaemiamechanical

9、 ventilation: 1)PEEP should be applied with caution 2)Low tidal volumes ( 6 mL/kg ) keep the end-inspiratory plateau pressure 3022acute PE: 1)The standard duration of anticoagulation should cover at least 3 months 2)unfractionated heparin (UFH) low molecular weight heparin (LMWH) fondaparinux 3)Pare

10、nteral heparin should overlap with the initiation of a vitamin K antagonist(over the first 510 days)1. 23high or intermediate clinical probability forPE: 1) parenteral anticoagulation should be initiated whilst awaiting the results of diagnostic tests 2) LMWH or fondaparinux are preferred over UFH f

11、or initial anticoagulation in PE, as they carry a lower risk of inducing major bleeding and heparin-induced thrombocytopenia (HIT). 3)UFH ：primary reperfusion serious renal impairment(creatinine clearance,30 mL/min) severe obesity2425Vitamin K antagonists:warfarin UFH, LMWH, or fondaparinux should b

12、e continued for at least 5 days and until INR has been 2.03.0 for two consecutive days26New oral anticoagulants: Dabigatran达比加群达比加群 Rivaroxaban利伐沙班利伐沙班:单药治疗单药治疗 Apixaban阿哌沙班阿哌沙班:单药治疗单药治疗 Edoxaban依杜沙班依杜沙班2728 indication：1)PE with shock or hypotension (I B)2)intermediate-high risk PE to permit early d

13、etectionof haemodynamic decompensation (rescue reperfusion therapy)(I B)The optimal time window： 1）within 48 hours of symptom onset 2) be useful for 614 days of symptom onset2930 1) Surgical embolectomy: high-risk PE, and intermediate-high-risk PE, particularly if thrombolysis is contraindicated or has failed.(IC) 2）Percutaneous catheter-directed treatment: an alternative to surgical pulmonary embolectomy for patients in whom full-dose sys