心力衰竭合并急性肺栓塞时血栓负荷与临床表现的相关性

Correlation between clot burden and clinical presentations in patients with acute pulmonary embolism and heart failure

目的探讨心力衰竭合并肺栓塞（pulmonaryembolism，PE）时血栓负荷与右室功能不全（fightventriculardysfunction，RVD）的相关性。方法选择首次发病的急性中危PE患者，根据既往是否存在心功能不全病史分为存在心功能不全PE组（Ⅰ组）和无心功能不全PE组（Ⅱ组）。由两位经验丰富的医学影像医师读取肺动脉增强cT（computedtomographypulmonaryarteriography，CTPA）中肺动脉的阻塞指数（obstructionscore，OS）和右心室／左心室（RV／LV）。结果最终入选152例急性中危PE患者，其中Ⅰ组35例（23％），Ⅱ组117例（77％）。两组0s（I组29．4％，Ⅱ组32．4％，P=0．083）、呼吸频率及心率比较差异均无统计学意义（P〉0．05）；I组LVEF显著低于Ⅱ组（Ⅰ组35．4％，Ⅱ组65．0％，P〈0．000），Ⅰ组低血压（P=0．031）、高脂血症（P=0．034）、冠状动脉粥样硬化性心脏病（P=0．045）、慢性肾病（P=0．024）和肺动脉高压（P=0．025）的比例显著高于Ⅱ组（P〈0．05）；I组氧合指数、RV／LV和平均动脉压（meanbloodpressure，MBP）均低于Ⅱ组（I组285．9，Ⅱ组328．5，P〈0．000；Ⅰ组0．91，Ⅱ组1．39，P〈0．000；I组62．2mmHg，Ⅱ组65．8mmHg，P=0．002）。Ⅰ组OS与RV／LV无显著相关性（r=0．086，P=0．962），与HR（r=0．010，P=0．542）、RR（r：0．132，P=0．192）无显著相关性（P〉0．05），与氧合指数呈显著负相关（r=-0．637，P=0．025），与MBP呈显著负相关（r=-0．610，P=0．036）。Ⅱ组OS与RV／LV呈显著正相关（r=0．624，P=0．000），与氧合指数（r=-0．473，P=0．032）和MBP（r=-0．570，P=0．036）呈中度负相关（P〈0．05），与HR（r=0．266，P=0．025）及RR（r=0．321，P=0．028）的相关性较弱。结论对于阻塞程度相同条件下的PE患者，右室功能不全作为间接判断PE阻塞严重程度的指标能否反映患者病情的严重程度，取决于患者原有的左心功能状态。存在左心功能不全时，右室功能不全尚不能反映血栓负荷程度。

Objective The purpose of our study is to assess the correlation between clot burden and clinical presentations in the submassive pulmonary embolism （PE） patients with preexisting heart failure. Methods All eligible patients were the first episode of submassive acute PE, and were classified as two groups based on with or without preexisting heart failure. Clinical presentations of the patients were collected on admission. Obstruction score and RV/LV ratio was calculated by two experienced of medical imaging practitioner on CT scan. Results A total of 152 submassive PE patientswere included in the final population. Thirty - five （23%） patients with previous cardiac inefficiency （group Ⅰ） and 117 （77%） patients without （group Ⅱ ） were enrolled. There were significant differences on the baseline condition, patients in group Ⅰ have higher proportion of hypertension （P = 0. 031 ）, dyslipidemia （ P = 0. 034 ） , coronary arteriosclerotic heart disease （ P = 0. 045 ）, chronic kidney disease （P = 0. 024）, and pulmonary hypertension （P = 0. 025 ） than those in the group Ⅱ. No significant correlation was found for CT obstruction score （OS） in the two groups （29.4 in group I vs. 32.4 in group 11 , P = 0. 083 ）. There were no significant differences in HR and RR between the two groups. Patients in group I showed much lowered LVEF than that in group Ⅱ（35.4 vs. 65.0, P 〈 0. 000）. Patients in group I showed lower oxygenation index, RV/LV and MBP than those in group Ⅱ （285.9 vs. 328.5, P〈0.000）, （0.91 vs. 1.39, P 〈0.000） and （62.2 mm Hg vs. 65.8 mm Hg, P =0. 002） respectively. In group I , OS didn＇t showed a direct correlation for RV/LV in group Ⅰ （r = 0. 086, P = 0. 962）. No significant correlation was also found for OS and HR （ r = 0.010, P = 0. 542） , and OS and RR （r =0. 132, P =0. 192）. OS showed a strong inverse correlation for oxygenation index （r = - O. 637, P = 0. 025 ） and a strong inverse correlation for MBP （r = - 0. 610, P = 0. 036）. In groupⅡ , OS showed a strong correlation for RV/LV （ r = 0. 624, P = 0. 000）, and a moderate inverse correlation both for oxygenation index （ r = - 0. 473, P = 0. 032） and MBP （ r = - 0. 570, P = 0.036）. On the other hand, correlations of OS with HR （r = 0. 266, P = 0. 025） and OS with RR （r = 0. 321, P = 0. 028） were weaker. Conclusion Patients show different clinical characteristics under the same OS condition due to different degree of cardiac function status. Different from most of the PE patients, patients with preexisting heart failure haven＇t shown obviously signs of tachycardia and tachypnea. RVD, as a marker for the severity of pulmonary obstruction, couldn＇t reflect the severity of pulmonary obstruction for the submassive PE patients with preexisting heart failure.