急性肺動脈栓塞及進(jìn)展心內(nèi)科

1、 Southwest HospitalSouthwest HospitalUpdate in 2010中國急性肺血栓栓塞癥診斷治療專家共識中國急性肺血栓栓塞癥診斷治療專家共識 第1頁/共103頁 Southwest HospitalSouthwest Hospital1 1、背景、背景2 2、臨床評估、臨床評估3 3、定量評估、定量評估4 4、治療、治療 抗凝抗凝 溶拴溶拴 手術(shù)手術(shù) 導(dǎo)管治療導(dǎo)管治療5 5、妊娠、妊娠PEPE6 6、非血栓、非血栓PEPE第2頁/共103頁 Southwest HospitalSouthwest Hospital1 1、背景、背景2 2、臨床評估、臨床評估3

2、3、定量評估、定量評估4 4、治療、治療 抗凝抗凝 溶拴溶拴 手術(shù)手術(shù) 導(dǎo)管治療導(dǎo)管治療5 5、妊娠、妊娠PEPE6 6、非血栓、非血栓PEPE第3頁/共103頁 Southwest HospitalSouthwest HospitalFIG 1. Venous thromboembolism (VTE)/100,000 population/year from 1990 through 1999.(Data from Stein et al.3-5)Curr Probl Cardiol 2010;35:314-376第4頁/共103頁 Southwest HospitalSouthwest

3、HospitalFIG 2. Deep venous thrombosis (DVT)/100,000 population/year shown according to age for the year 1999.6,7 (Reprinted with permission.10)Curr Probl Cardiol 2010;35:314-376第5頁/共103頁 Southwest HospitalSouthwest HospitalFIG 3. Pulmonary embolism (PE)/100,000 population/year shown according to age

4、 for the year 1999. (Data from Stein et al.5,6) (Reprinted with permission.10)Curr Probl Cardiol 2010;35:314-376第6頁/共103頁 Southwest HospitalSouthwest HospitalFIG 12. Estimated case fatality rates for PE according to decades of age. (Reprinted with permission.23)Curr Probl Cardiol 2010;35:314-376第7頁/

5、共103頁 Southwest HospitalSouthwest HospitalFIG 4. PE and DVT in children. (Data from Stein et al.7)Curr Probl Cardiol 2010;35:314-376第8頁/共103頁 Southwest HospitalSouthwest Hospital Major risk factors for venous thrombosis Major surgery Orthopaedic surgery to lower limb/lower limb trauma History of pre

6、vious venous thrombosis Cancer Pregnancy/puerperium Reduced mobility major illness with prolonged bed rest Age 70 years Thrombophilias: antithrombin deficiency protein C deficiency protein S deficiency antiphospholipid antibodies第9頁/共103頁 Southwest HospitalSouthwest Hospital1 1、背景、背景2 2、臨床評估、臨床評估3 3

7、、定量評估、定量評估4 4、治療、治療 抗凝抗凝 溶拴溶拴 手術(shù)手術(shù) 導(dǎo)管治療導(dǎo)管治療5 5、妊娠、妊娠PEPE6 6、非血栓、非血栓PEPE第10頁/共103頁 Southwest HospitalSouthwest Hospital TABLE 5. Electrocardiographic manifestations: patients without prior cardiac or pulmonary diseaseData from Stein et al.29,57 Reprinted with permission.10Some patients had more than

8、1 abnormality.Curr Probl Cardiol 2010;35:314-376第11頁/共103頁 Southwest HospitalSouthwest HospitalTABLE 6. Plain chest radiograph in patients with acute pulmonary embolism and no prior cardiopulmonary diseaseData are from Stein et al.29,63 Reprinted with permission.10aAmong patients with a pleural effu

9、sion, 86% had only blunting of the costophrenic angle.None had a pleural effusion that occupied more than one third of a hemithorax.bProminent central pulmonary artery and decreased pulmonary vascularity.肺實質(zhì)異常肺不張/萎陷肺實變胸水第12頁/共103頁 Southwest HospitalSouthwest HospitalFIGURE 2. V/QSPECT for the detect

10、ion of pulmonary embolismV/QSPECT thermal imaging coronal posterior sections in a female patient show multiple large pulmonary-ventilatory areas of mismatch that indicate pulmonary emboli that involve the upper and lower lobes of the right lung (white arrows).V/QSPECT, ventilation and perfusion sing

11、le photon emission computed tomography.第13頁/共103頁 Southwest HospitalSouthwest HospitalFIG 19. Relative use of diagnostic imaging tests in patients hospitalized with PE from 1979 through 2006. V/Q, ventilation/perfusion; ANGIOS, pulmonary angiograms. (Reprinted with permission.10)Curr Probl Cardiol 2

12、010;35:314-376第14頁/共103頁 Southwest HospitalSouthwest HospitalFIG 20. CT pulmonary angiogram showing PE in the right pulmonary artery.Curr Probl Cardiol 2010;35:314-376第15頁/共103頁 Southwest HospitalSouthwest HospitalFIG 21. CT venous phase image showing right popliteal vein thrombosis (arrow).Curr Pro

13、bl Cardiol 2010;35:314-376第16頁/共103頁 Southwest HospitalSouthwest Hospital Three images from a single computed tomography pulmonary angiography (CTPA) study performed with a high clinical suspicion of pulmonary embolism (PE). Image 1 demonstrates a large PE in the proximal right pulmonary artery. Ima

14、ge 2 shows a significant concurrent pneumothorax. Image 3 demonstrates an RV/LV ratio 1 signifying significant right ventricular (RV) dysfunction. Together these images show the high utility of CTPA in diagnosis/exclusion of PE, diagnosis/exclusion of differential diagnoses, and in risk stratifying

15、a patient so as to guide therapy.第17頁/共103頁 Southwest HospitalSouthwest Hospital Causes of a raised D-dimer venous thromboembolic disease increasing age cancer infection haematoma post surgery inflammation pregnancy peripheral vascular disease liver disease第18頁/共103頁 Southwest HospitalSouthwest Hosp

16、ital The Thrombo-Embolism Lactate Outcome Study 血栓血栓- -栓塞乳酸鹽轉(zhuǎn)歸研究栓塞乳酸鹽轉(zhuǎn)歸研究 Prognostic Value of Plasma Lactate Levels Among Patients With Acute Pulmonary Embolism 血漿乳酸鹽水平在PE患者中的預(yù)后價值A(chǔ)nn Emerg Med. 2012;xx:xxxTable 2. Description of 30-day outcome of patients investigated (n=270).*第19頁/共103頁 Southwest H

17、ospitalSouthwest HospitalFigure 3. All-cause death and composite endpoint incidence in patients with increasing values of plasma lactate level.乳酸鹽水平與全因死亡和復(fù)合終點乳酸鹽水平與全因死亡和復(fù)合終點Ann Emerg Med. 2012;xx:xxx第20頁/共103頁 Southwest HospitalSouthwest HospitalFigure 4. Cox proportional hazard analysis of the rela

18、tionship between plasma lactate level greater than or equal to 2 mmol/L and outcome in 270 patients withacute pulmonary embolism.Ann Emerg Med. 2012;xx:xxx全因死亡全因死亡復(fù)合終點復(fù)合終點第21頁/共103頁 Southwest HospitalSouthwest HospitalFigure 5. Receiver operating characteristic curve analysis of plasma lactate level

19、, troponin I level, and sPESI values in 270 patients with acute pulmonary embolism.Ann Emerg Med. 2012;xx:xxx第22頁/共103頁 Southwest HospitalSouthwest HospitalElevated Heart-Type Fatty Acid-Binding Protein Levels on Admission Predict an Adverse Outcome in Normotensive Patients With Acute Pulmonary Embo

20、lism 心肌脂肪酸結(jié)合蛋白水平升高預(yù)測血壓正常的心肌脂肪酸結(jié)合蛋白水平升高預(yù)測血壓正常的APE病人不良轉(zhuǎn)歸病人不良轉(zhuǎn)歸(J Am Coll Cardiol 2010;55:21507)Figure 1 Prognostic Sensitivity and Specificity of H-FABP, cTnT, and NT-proBNPReceiver operating characteristic curves for heart-type fatty acid-binding protein (H-FABP), cardiac troponin T (cTnT), and N-ter

21、minal pro-brain natriuretic peptide (NT-proBNP) levels on admission with regard to a complicated 30-day outcome. AUC area under the curve.第23頁/共103頁 Southwest HospitalSouthwest Hospital Figure 2 Combination of H-FABP With Clinical ParametersThe number of patients with complications and the overall n

22、umber of patients are given, along with percentages, for each column. H-FABP heart-type fattyacid binding protein; HR heart rate; RV right ventricular.第24頁/共103頁 Southwest HospitalSouthwest HospitalFigure 3 Probability of Long-Term Survival in Patients With or Without Elevation of H-FABP, cTnT, and

23、NT-proBNPBiomarker levels were dichotomized, and elevated concentrations were defined as those 6 ng/ml for H-FABP, 0.04 ng/ml for cTnT, and 1,000 pg/ml forNT-proBNP. Red lines elevated values; blue lines normal values; p values were calculated by the log-rank test. Abbreviations as in Figure 1.JACC

24、2010; 55(19): 21507第25頁/共103頁 Southwest HospitalSouthwest Hospital Fig. 1. Pathophysiology of right ventricular dysfunction during acute pulmonary embolism. RV: Right ventricule; LV: Left ventricle; TXA2: Thromboxane-A2; ET: Endothelin; PGF2a: Prostaglandin F2a ; PGI2: Prostacyclin. Grey arrow indic

25、ates that all constituted a vicious cycle. Black arrow indicates pathophysiology change. J Med Coll PLA 2010；25：235-246 第26頁/共103頁 Southwest HospitalSouthwest HospitalTable 2 Echocardiographic risk assessment in PE1. Diagnostic criteria for RV dysfunction RV功能不全的標(biāo)準(zhǔn)功能不全的標(biāo)準(zhǔn) A. RV wall hypokinesis -Mod

26、erate or severe -McConnells sign regional RV hypokinesis in which the apex is spared B. RV dilatation -End-diastolic diameter 30 mm in parastemal view -RV larger than LV in sobcostal or apical view -Increased tricuspid velocity 26 m/sec -Paradoxical RV septal systolic motion C. Pulmonary artery hype

27、rtension -Pulmonary artery systolic pressure 30 mmHg -Dilated IVC with lack of respiratory collapse2. Other factors associated with increased mortality A. Patent foramen ovale B. Free-floating night-heat thrombus第27頁/共103頁 Southwest HospitalSouthwest HospitalFig. 1 Physician assessment of patients w

28、ith PE.PE的臨床評估的臨床評估第28頁/共103頁 Southwest HospitalSouthwest Hospital1 1、背景、背景2 2、臨床評估、臨床評估3 3、定量評估、定量評估4 4、治療、治療 抗凝抗凝 溶拴溶拴 手術(shù)手術(shù) 導(dǎo)管治療導(dǎo)管治療5 5、妊娠、妊娠PEPE6 6、非血栓、非血栓PEPE第29頁/共103頁 Southwest HospitalSouthwest Hospital Assessment of clinical probabilityRevised Geneva Score PointsAge 60 years 1Previous VTE 3S

29、urgery/fracture lower limb in last month 2Active malignancy 2Unilateral lower limb pain 3Haemoptysis 2Heart rate 7594 3Heart rate 95 5Pain on lower limb deep venous palpation andunilateral oedema 4Clinical probability Total points Low 03 Intermediate 410 High 10第30頁/共103頁 Southwest HospitalSouthwest

30、 Hospital Modified Wells score 6 PointsSymptoms of a DVT 3No alternative diagnosis 3Heart rate 100 1.5Immobilization or surgery in the previous month 1.5Previous VTE 1.5Malignancy 1.5Haemoptysis 1.5Score 4 or less, PE unlikely第31頁/共103頁 Southwest HospitalSouthwest HospitalTABLE 12. Positive predicti

31、ve values of CTA and CTA/CTV in relation to prior clinical assessmentOnly patients with a reference test diagnosis by V/Q scan or conventional pulmonary DSA were included.Abbreviations: CTA, computed tomographic pulmonary angiography; CTV, venous phase venogram. Reprinted with permission.14Curr Prob

32、l Cardiol 2010;35:314-376第32頁/共103頁 Southwest HospitalSouthwest HospitalTABLE 13. Negative predictive values of CTA and CTA/CTV in relation to prior clinical assessmentOnly patients with a reference test diagnosis by V/Q scan or conventional pulmonary DSA were included.Abbreviations: CTA, computed t

33、omographic pulmonary angiography; CTV, venous phase venogram.Reprinted with permission.14Curr Probl Cardiol 2010;35:314-376第33頁/共103頁 Southwest HospitalSouthwest Hospital BTS score PointsIs a PE a reasonable diagnosis? 1PE的診斷合理的診斷合理? Is an alternative diagnosis less likely? 1可能性小可能性小? Is a major ris

34、k factor present? 1存在主要危險因素存在主要危險因素? 1 point, low clinical probability; 2 points, intermediate clinical probability;3 points, high clinical probability.第34頁/共103頁 Southwest HospitalSouthwest Hospital1 1、背景、背景2 2、臨床評估、臨床評估3 3、定量評估、定量評估4 4、治療、治療 抗凝抗凝 溶拴溶拴 手術(shù)手術(shù) 導(dǎo)管治療導(dǎo)管治療5 5、妊娠、妊娠PEPE6 6、非血栓、非血栓PEPE第35頁/

35、共103頁 Southwest HospitalSouthwest HospitalFig. 3 Pathophysiology of RV dysfunction and death in PE.第36頁/共103頁 Southwest HospitalSouthwest Hospital循環(huán)的維持：循環(huán)的維持：Increasing MAP (i.e. filling and pressor support) Reducing RVPm (i.e. reducingPAPs/pulmonary vascular) resistance(selective pulmonary vasodila

36、tors (e.g. nitric oxide or inhaled prostacyclin) though these may result in systemic hypotension增加增加MAP，降低，降低RVPm，盡管可以導(dǎo)致體循環(huán)低血壓，盡管可以導(dǎo)致體循環(huán)低血壓Noradrenaline can counteract these concerns to a degree and is also the preferred inotrope for its concomitant beneficial alpha and beta-adrenergic effects on MA

37、P and cardiac output respectively去甲腎上腺素：增加去甲腎上腺素：增加MAP 和和 COInotropes that have systemic vasodilatory effects (such as milrinone ordobutamine) which may increase cardiac output without increasingMAP and therefore not significantly improve RVCPP具有體循環(huán)血管擴(kuò)張作用的藥物（米力農(nóng)、多巴酚丁胺）可增加具有體循環(huán)血管擴(kuò)張作用的藥物（米力農(nóng)、多巴酚丁胺）可增加

38、CO，但不增加，但不增加MAP，而不顯著改善，而不顯著改善RVCPP Right ventricular coronary perfusion pressure (RVCPP = MAP - RVPm)ANAESTHESIA AND INTENSIVE CARE MEDICINE 2010；11:12第37頁/共103頁 Southwest HospitalSouthwest Hospital Anticoagulation 抗凝：抗凝：有充分理由支持診斷有充分理由支持診斷PE：開始全劑量的：開始全劑量的LMUH治療治療由影像學(xué)證實和確診由影像學(xué)證實和確診PE：停：停LMUH 改為改為warf

39、arin（INR=2-3，目標(biāo)，目標(biāo)=2.5） 為門診病人安排監(jiān)測為門診病人安排監(jiān)測 INR第38頁/共103頁 Southwest HospitalSouthwest Hospital Suggested dosing, heparin therapyANAESTHESIA AND INTENSIVE CARE MEDICINE 2010；11:12第39頁/共103頁 Southwest HospitalSouthwest Hospital How long to treat?根據(jù)根據(jù)PE的原因而異的原因而異 通常通常6W-3M 可能足夠可能足夠 病因持續(xù)存在病因持續(xù)存在: 抗凝持續(xù)抗凝持

40、續(xù) 原發(fā)原發(fā)/先天性先天性PE,一旦停止治療一旦停止治療,復(fù)發(fā)率復(fù)發(fā)率410%/年，年，4年以上遠(yuǎn)期事年以上遠(yuǎn)期事 件率件率20% 因此因此, I級事件后應(yīng)終身抗凝治療級事件后應(yīng)終身抗凝治療,但需要權(quán)衡治療的獲益與風(fēng)險但需要權(quán)衡治療的獲益與風(fēng)險 嚴(yán)重出血嚴(yán)重出血(顱內(nèi)出血；腹膜后出血；顱內(nèi)出血；腹膜后出血；Hb降低需要輸血者）：降低需要輸血者）： 75歲歲 1% /年年 75歲歲 5% /年年 決策治療療程前與病人決策治療療程前與病人 / 家屬討論利弊是明智家屬討論利弊是明智/必要的必要的 第40頁/共103頁 Southwest HospitalSouthwest HospitalFig.

41、2. Percentage and size of residual pulmonary thrombi. Greater, similar and smaller occlusion mean bigger, same and lesser size of pulmonary thrombi respectively as seen in second computed tomography.Eur J Int Med 2012；23 ：379383Eur J Int Med 2012；23 ：379383Residual pulmonary thromboemboli after acut

42、e pulmonary embolism 繼發(fā)于肺栓塞的殘余肺血栓繼發(fā)于肺栓塞的殘余肺血栓第41頁/共103頁 Southwest HospitalSouthwest HospitalEur J Int Med 2012；23 ：379383Residual pulmonary thromboemboli after acute pulmonary embolism 繼發(fā)于肺栓塞的殘余肺血栓繼發(fā)于肺栓塞的殘余肺血栓第42頁/共103頁 Southwest HospitalSouthwest HospitalTable 1 Causes of non-repeated CT angiograph

43、yCauses N (%) Cognitive impairment 5 (11)Mobility impairment 17 (37)Renal failure 4 (9)Death 9 (19)Living out of our community 6 (13)Pregnancy 1 (2)Rejection 4 (9)Eur J Int Med 2012；23 ：379383Residual pulmonary thromboemboli after acute pulmonary embolism 繼發(fā)于肺栓塞的殘余肺血栓繼發(fā)于肺栓塞的殘余肺血栓第43頁/共103頁 Southwest

44、 HospitalSouthwest Hospital Lifelong treatment is appropriate if:The initial PE was lifethreateningPE威脅生存威脅生存The patient has significant cardiorespiratory disease患者有顯著的心肺疾病患者有顯著的心肺疾病Whereby a further, even small, PE could have fatal consequences;or the patient has a second, unprovoked eventPE可能有致命性后

45、果，或有再次無緣無故的事件可能有致命性后果，或有再次無緣無故的事件第44頁/共103頁 Southwest HospitalSouthwest Hospital INR INR 達(dá)標(biāo)達(dá)標(biāo): PE: PE的復(fù)發(fā)是罕見的的復(fù)發(fā)是罕見的如果復(fù)發(fā)：增加如果復(fù)發(fā)：增加 warfarinwarfarin、增大目標(biāo)、增大目標(biāo) INRINR 癌癥患者癌癥患者（復(fù)發(fā)更常見）：轉(zhuǎn)換為（復(fù)發(fā)更常見）：轉(zhuǎn)換為LMWHLMWH在抗凝治療中仍存在在抗凝治療中仍存在DVTDVT，或抗凝禁忌：腔靜脈濾器（可回收式），或抗凝禁忌：腔靜脈濾器（可回收式） 第45頁/共103頁 Southwest HospitalSouthwes

46、t Hospital 抗凝：嚴(yán)重出血并發(fā)癥抗凝：嚴(yán)重出血并發(fā)癥 3%漏診漏診PE：死亡風(fēng)險：死亡風(fēng)險 30%提示：確診的提示：確診的PE、臨床高度、臨床高度PE風(fēng)險者均應(yīng)抗凝，除非有明確禁忌癥風(fēng)險者均應(yīng)抗凝，除非有明確禁忌癥ANAESTHESIA AND INTENSIVE CARE MEDICINE 2010；11:12第46頁/共103頁 Southwest HospitalSouthwest HospitalNew Drug ReviewDabigatran Etexilate: An Oral Direct Thrombin Inhibitor forthe Management of

47、 Thromboembolic Disorders 達(dá)比加群：口服的直接凝血酶抑制劑達(dá)比加群：口服的直接凝血酶抑制劑Clin Ther. 2012;34:766787Table I. Pertinent drug interactions with dabigatran第47頁/共103頁 Southwest HospitalSouthwest HospitalTable II. Pertinent clinical studies on the use of dabigatran.第48頁/共103頁 Southwest HospitalSouthwest HospitalBISTRO I

48、Boehringer Ingelheim Study in Thrombosis I; DE dabigatran etexilate; DVT deep vein thrombosis; PE pulmonary embolism; QD daily; RE-NOVATE Prevention of Venous ThromboembolismAfter Total Hip Replacement; VTE venous thromboembolism; RE-MODEL Thromboembolism Prevention After Knee Surgery; RE-MOBILIZE D

49、abigatran Versus Enoxaparin in Preventing Venous ThromboembolismFollowing Total Knee Arthroplasty; RE-COVERDabigatran Versus Warfarin in the Treatment of Acute Venous Thromboembolism; INRinternational normalized ratio; PETROPrevention of Embolicand Thrombotic Events in Patients With Persistent Atria

50、l Fibrillation; AF atrial fibrillation; RE-LY Randomized Evaluation of Long-term Anticoagulation Therapy; Postop postoperation.*P 0.05 for enoxaparin.P 0.05 indicating non-inferior to enoxoparin.P 0.0001 indicating non-inferior to warfarin.P 0.05 significantly different from warfarin.P 0.001 indicat

51、ing non-inferior to warfarin.P 0.001 indicating superior to warfarin.第49頁/共103頁 Southwest HospitalSouthwest Hospital Thrombolysis 溶栓溶栓巨大巨大PE：常伴心血管病，有或無紫紺、靜脈怒張、搏動，：常伴心血管病，有或無紫紺、靜脈怒張、搏動，P2亢進(jìn)亢進(jìn)雖然確診應(yīng)該基于影象結(jié)果，因為大的雖然確診應(yīng)該基于影象結(jié)果，因為大的PE危急，通常難以轉(zhuǎn)送至放射科進(jìn)危急，通常難以轉(zhuǎn)送至放射科進(jìn)行行CTPA床旁床旁UCG可提供有價值的信息：急性右心負(fù)荷過重可提供有價值的信息：急性右心負(fù)

52、荷過重不能解釋的心肺衰竭病人，因為病情太不穩(wěn)定，無法不能解釋的心肺衰竭病人，因為病情太不穩(wěn)定，無法CTPA、甚至床旁、甚至床旁UCG，假定基于危險評估和臨床表現(xiàn)而擬診，假定基于危險評估和臨床表現(xiàn)而擬診PE：alteplase（阿替普酶）（阿替普酶）50mg巨大巨大PE，顯著或進(jìn)行性血動力學(xué)不穩(wěn)定（溶栓可能戲劇性改善血動力學(xué)和，顯著或進(jìn)行性血動力學(xué)不穩(wěn)定（溶栓可能戲劇性改善血動力學(xué)和氧合狀態(tài)氧合狀態(tài)病死率和病死率和PE復(fù)發(fā)率低于肝素療法，但幾天內(nèi)血凝塊的解析度則不如，復(fù)發(fā)率低于肝素療法，但幾天內(nèi)血凝塊的解析度則不如，缺乏頭對頭研究結(jié)果，缺乏頭對頭研究結(jié)果，meta-analysis傾向溶栓療法，

53、因為顯著降低了病傾向溶栓療法，因為顯著降低了病死率死率submassive PE患者，溶栓后顯著減少了進(jìn)患者，溶栓后顯著減少了進(jìn)CCU的需求程度的需求程度 ANAESTHESIA AND INTENSIVE CARE MEDICINE 2010；11:12第50頁/共103頁 Southwest HospitalSouthwest Hospital 溶栓劑和方案溶栓劑和方案（Thrombolytic agents and regimens） Streptokinase 250,000 U as a loading dose over 30 min,鏈激酶鏈激酶 followed by 100,

54、000 U per hour over 1224 h Accelerated regimen: 1.5 million IU over 2 hUrokinase 4400 U per kilogram of body weight as a loading dose over 10 min, 尿激酶尿激酶 followed by 4400 U/kg/h over 1224 h Accelerated regimen: 3 million U over 2 hAlteplase 100 mg over 2 h阿替普酶阿替普酶 Accelerated regimen: 0.6 mg/kg over

55、 15 minReteplase Two bolus injections of 10 U 30 min apart瑞替普酶瑞替普酶Tenecteplase 3050 mg bolus over 510 s 替奈普替奈普酶酶 adjusted for body weight: 60 kg: 30 mg 6070 kg: 35 mg 7080 kg: 40 mg 8090 kg: 45 mg 90 kg: 50 mg第51頁/共103頁 Southwest HospitalSouthwest Hospital No study has shown a significant difference

56、 in the efficacy of different thrombolytic agents 尚無研究表明不同溶栓劑效果有顯著差異尚無研究表明不同溶栓劑效果有顯著差異A suggested protocol of two 10 unit doses of Reteplase, separated by 30 minutes, is effective and simple建議建議2個個10u 瑞替普酶，間隔瑞替普酶，間隔30minThere is no evidence that using a central venous or pulmonary artery (PA) cathet

57、er for administering thrombolytics confers a treatment advantage or any reduction in bleeding complications， may result in arterial injury，pneumothorax沒有證據(jù)表明使用沒有證據(jù)表明使用CV/PA導(dǎo)管給藥具有治療優(yōu)勢和減少出血并發(fā)癥，而可致動脈導(dǎo)管給藥具有治療優(yōu)勢和減少出血并發(fā)癥，而可致動脈損傷、氣胸?fù)p傷、氣胸Major bleeding： 10% vs. 3% with heparin infusion alone,Intracerebral h

58、aemorrhage： 0.5%嚴(yán)重出血并發(fā)癥嚴(yán)重出血并發(fā)癥 10%，顱內(nèi)出血，顱內(nèi)出血15 minutes) hypotension (systolic BP 40 mmHg) 持續(xù)低持續(xù)低BP（15 min），或），或SBP持續(xù)顯著下降持續(xù)顯著下降(40 mmHg）Mortality exceeding 25% (65% if cardiopulmonary resuscitation is required) 65% 需要需要CPR者，者，病死率超過病死率超過25% Acute RV failure is a very common feature 急性急性RVF十分常見十分常見Ther

59、e may only be a brief window of opportunity to identify and address the condition 可供識別和處理的時間窗很短可供識別和處理的時間窗很短Patients remain at significant risk of death for several days after an event 幾天內(nèi)死亡風(fēng)險仍很高幾天內(nèi)死亡風(fēng)險仍很高第53頁/共103頁 Southwest HospitalSouthwest Hospital Submassive PE 次大次大PETypically describes other a

60、cute PEs典型的急性典型的急性PE癥狀癥狀Normal blood pressure血壓正常血壓正常Patients may have evidence of RV dysfunction(best confirmed with echocardiography, but also possibly shown on CT)右心室功能不全的癥狀（右心室功能不全的癥狀（UCG，CT）This subgroup has up to four times the mortality risk and increased rates of recurrence,may also go on to