中危急性肺栓塞患者溶栓治疗的安全性及有效性

Safety and efficacy of the thrombolytic therapy in submissive pulmonary thromboembolism

目的通过前瞻性非随机的对照研究，探讨中危组急性肺栓塞患者接受溶栓治疗的安全性及有效性。方法连续选择首都医科大学附属北京安贞医院急诊重症监护室2005年6月至2012年5月期间明确诊断的中危组急性肺栓塞177例，其中接受溶栓治疗患者102例，抗凝治疗75例，分别对其在接受治疗后2h、24h、7d的临床症状、客观指标、肺动脉增强CT及肺灌注通气结果进行评价，数据处理采用配对t检验和）（。检验进行统计学分析。结果①两组患者基础病比较差异无统计学意义（P〉0．05），溶栓组出血6例（5．9％），抗凝组1例（1．3％）（P〈0．05），均无致命性出血病例发生；②溶栓组患者治疗2h呼吸、心率、血压的变化差异具有统计学意义（P〈0．01）；治疗24h肺动脉收缩压及三尖瓣返流速度明显改善（P〈0．01）；与溶栓组相比，差异具有统计学意义（P〈0．01）；③溶栓治疗7d后双下肢深静脉超声显示显效率、好转率分别为83％和96．2％；肺血管增强CT及肺灌注／通气显示显效率、好转率分别为66．7％和98％，明显优于抗凝组（P〈0．01）；④亚组分析结果显示：发病3d内患者溶栓治疗后的显效率明显高于病程3d以上者（P〈0．01）。结论①中危肺栓塞患者接受溶栓治疗是安全的，强调除外新发不典型脑血管意外事件；②溶栓治疗在2h内迅速缓解中危肺栓塞患者的急性症状；③治疗7d血栓负荷变化提示溶栓组显效率优于抗凝组；④溶栓治疗效果取决于病程。

Objective To study prospectively the safety and efficacy of the thromblytic therapy in acute submassive pulmonary thromboembolism （PTE） without randomized control. Methods A total of consecutive 177 patients with acute submassive PTE admitted to the emergency intensive care unit were screened from June of 2005 to May of 2012. After a comprehensive screening, 102 patients were treated with thrombolytic therapy （ TT group ）, and 75 with anticoagulation therapy （ AT group ）. Clinical signs and physical examination findings were recorded 2 hours, 24 hours and 7 days after treatment. Echocardiography （ECG） was repeated 24 hours later. Lung perfusion scan and CT pulmonary artery （CTPA） were repeated on the 7th day. All data was analyzed by paired t test and Chi-square test. Results ①Bleeding happened in 6 patients of TY group and in 1 patient of AT group （P 〉 0. 05）, and no lethal hemorrhage occurred in the two groups. There were no statistically significant differences in demographics and clinical history of patients between Tr group and AT group （P 〉 0. 05）. ②There were statistically significant changes in respiratory rate, heart rate and systolic blood pressure in the TT group 2 hours after treatment and great changes insystolic pressure of pulmonary artery （SPAP） and tricuspid regurgitation at 24 hours after treatment （ P 〈 0. 01 ） , whereas obvious change in respiratory rate in AT group was found 24 hours after treatment. ③In the TT group 7 days after treatment, significant efficiency rate and total improvement of the deep vein thrombosis （DVT） identified by uhrasonography were 83.0% and 96. 2% respectively, and those of CTPA and lung perfusion scan were 66. 7% and 98% respectively. The efficiency of TT was significantly superior over AT in this respect （ P 〈 0. 01 ）. ④The efficiency of TT given within 3 days after onset of PTE was significantly higher than that of TT conferred over 3 days after onset of PTE （ P 〈 0. 01 ）. Conclusions ①Thrombolytic therapy is safe and effective for the submassive PTE, but atypical cerebrovascular accident must be rule out first. ②Thrombolytie therapy can improve the symptom of the patient in 2 hours compare with AT. ③ Thrombus burden can be reduced more obviously in TT group after 7 days treatment compare with the AT group. ④The effect of thrombolytic therapy depends on the time as ti given during the course of disease, the earlier administration the better efficacy.