急性肺栓塞患者规范抗凝中复发的特征及其相关因素

Features of recurrent pulmonary embolism and its relevant factors in the patients with acute pulmonary embolism during adequate anticoagulation therapy

目的探讨无明确触发因素的肺栓塞(pulmonary embolism,PE)患者规范抗凝治疗中PE复发特征及其相关因素.方法连续收集2017年1月至2018年8月北京安贞医院急诊重症监护室(emergency intensive care unit,EICU)收治的无明确触发因素的急性PE患者,病情稳定按照研究拟定的随访方案进行院外随访;记录患者抗凝治疗情况、急性期及抗凝治疗1年时肺灌注/通气显像(ventilation/perfusion scan,V/Q scan)结果及每3个月检测的血压、糖化血红蛋白、同型半胱氨酸及血脂等动脉硬化相关指标的结果.结果连续纳入175例急性PE患者中符合入选标准的急性PE患者共70例,平均年龄64(64.22±10.94)岁;70例急性PE患者中59例(84.3%)患者具有一个或多个动脉硬化的危险因素;PE复发组20例(复发率28.57%),V/Q scan明确提示原有部位加重或新发部位的灌注缺损,均为无症状PE复发,治疗后灌注缺损面积较治疗前有所减小,但差异未见统计学意义(P>0.05).50例无PE复发患者治疗后灌注缺损面积显著减小(P<0.001);冠状动脉危险因素中,低密度脂蛋白(low density lipoprotein,LDL)累积暴露水平与PE复发相关:LDL每增加1 mmol/L,PE复发风险增加了47.6%(OR 1.476,95%CI1.108~1.964,P<0.05).结论①亟需建立急性PE患者的院外随访策略;②V/Q scan可以确定抗凝期间无症状PE复发的患者,有助于抗凝1年后疗程的确定;③LDL增加与PE复发风险增加有关.

Objective To study the features of recurrent pulmonary embolism(P E)and the association between recurrence PE and atherosclerotic risk factors in unprovoked PE patients during adequate anticoagulation therapy after discharged from hospital.Methods Patients with a first episode of unprovoked acute PE admitted to emergency intensive care unit(E IC U)of Beijing Anzhen hospital from January 2017 to August 2018 were consecutively recruited.Patients were followed-up for one year according to our strategy and relevant data were recorded,including the param eters about anticoagulation therapy,lung ventilation/perfusion scan(V/Q scan)on admission and after 1-year follow-u p,level of the atherosclerotic risk factors including glycated hem oglobin,hyperhom ocysteinem ia,hypertriglyceridem ia,hypercholesterolem ia,high-density lipoprotein,low-density lipoprotein(LDL)every three months.Results There were 175 PE patients admitted in EICU from January 2017 to August 2018,and 70 patients(mean age 64 years)with a first episode of unprovoked acute PE after one-year adequate anticoagulation therapy were involved.There were 59 PE patients(84.3%)with one or more atherosclerotic risk factors among 70 PE patients.There were 50 patients in non-recurrent PE group,and there were significant improvement in the area of perfusion defection shown in V/Q scan(P<0.001).W hereas,20 PE patients were in the recurrent PE group(recurrent rate 28.57%)with perfusion defection worse or new site shown in V/Q scan,and no significant statistical differences were found despite improvement in different degrees(P>0.05).Cumulative exposure rate of LDL was associated with recurrent P E,and every 1 mmol/L increased in LDL,the risk of PE recurrence increased by 47.6%(OR 1.476,95%Cl 1.108-1.964,P<0.05).Conclusion①A follow-up strategy is urgently needed for acute unprovoked PE patients after discharged from hospital.②V/Q scan as an effective means could offer the evidence of asymptomatic recurrence in unprovoked PE patients during one-year anticoagulation therapy,and gives the doctors evidences to decide the course of anticoagulation treatment.③Elevation of LDL associates with the risk of PE recurrence.