特发性肺血栓栓塞症33例临床回顾性分析

Idiopathic pulmonary thromboembolism： a retrospective analysis of 33 cases

目的了解特发性肺栓塞的临床特点，提高特发性肺栓塞的诊治水平。方法对2010年7月至2012年2月于解放军总医院无获得性血栓形成高危因素的33例特发性肺栓塞住院患者的一般资料、临床表现、辅助检查、误诊情况及治疗进行统计学分析。结果本组特发性肺栓塞病例性别差异无统计学意义，平均年龄（57．6±14．1）岁，平均体质量指数（26．4±3．2）。临床表现以呼吸困难（97．0％）和胸痛（30．3％）为主。实验室检查中，D-二聚体〉0．5mg／L者30例（90．9％），脑利钠肽〉150ng／L者15例（57．7％），Pa02〈75mmI-Ig者15例（51．7％）。心电图主要以V1～V4ST-T改变（60．6％）为主，超声心动图主要表现为肺动脉压力升高，血管螺旋CT及肺动脉造影表现为不同程度的充盈缺损。首诊误诊以急性心肌梗死及肺炎多见，误诊率达69．7％。本组病例均采用抗凝治疗，部分患者行溶栓和（或）介入治疗。结论特发性肺栓塞因缺乏易感因素而易误诊，应综合临床表现、D-二聚体及影像学检查确定疑诊患者，并尽快行肺动脉造影检查确诊。

Objective To investigate the clinical characteristics of idiopathic pulmonary embolism for better diagnosis and treatment. Methods Thirty-three cases with identified pulmonary embolism but without acquired high-risk factors for embolism formation who admitted to Chinese PLA General Hospital from July 2010 to February 2012 were enrolled in this study. Their clinical data including general information, clinical signs and symptoms, examinations, real-diagnosis and treatment were collected and retrospectively analyzed. Results There was no significant difference between male and female patients in the incidence of idiopathic pulmonary embolism. The cohort was at a mean age of （57.6 ± 14.1） years and a mean body mass index of （26.4 ± 3.2）. Dyspnea （97.0%） and chest pain （30.3%） were the most common symptoms. In laboratory examination, 30 cases （90.9%） had D-Dimer over 0.5mg/L, 15 cases （57.7%） had BNP exceeding 150ng/L, and 15 cases （51.7%） had PaO2 lower than 75 mmHg. V1 - V4 ST-T wave changes were common in electrocardiogram （60.6%）, and elevated pulmonary arterial pressure was common in ultrasonic cardiogram. Vascular spiral computed tomography and pulmonary angiography showed filling defects at different degrees. The most common misdiagnosis of first visit was acute myocardial infarction and pneumonia, with a misdiagnosis rate of 69.7%. Anticoagulation was carried out for all the patients. Some patients accepted thrombolysis and/or interventional therapy. Conclusion Idiopathic pulmonary embolism is prone to be misdiagnosed because of lacking predisposing factors. Suspicious patients should be decided by combined consideration in terms of clinical manifestations, D-Dimer and imaging, and pulmonary angiography should be conducted as soon as possible to confirm the diagnosis.