2008ESC急性肺动脉栓塞指南解读

Guidelinesonthediagnosisandmanagementofacutepulmonaryembolism——2008ESCClassesofrecommendationsLevelsofevidencePredisposingfactorsPredisposingfactorsforvenousthromboembolism:Table3NaturalhistoryTheriskofVTEaftersurgeryishighestduringthefirst2weeksaftersurgerybutremainselevatedfor2–3months.AntithromboticprophylaxissignificantlyreducestheriskofperioperativeVTE.Thelongerthedurationofantithromboticprophylaxis,thelowertheincidenceofVTE.MostpatientswithsymptomaticDVThaveproximalclots,andin40–50%ofcasesthisconditioniscomplicatedbyPE,oftenwithoutclinicalmanifestations.AsymptomaticPEiscommoninthepostoperativephase,particularlyinpatientswithasymptomaticDVTwhoarenotgivenanythromboprophylaxisPEoccurs3–7daysaftertheonsetofDVTshockorhypotensionin5–10%ofcases,andinupto50%ofcaseswithoutshockbutwithlaboratorysignsofrightventriculardysfunction(RVD)and/orinjury,whichindicatesapoorerprognosis.completeresolution;two-thirdsofallpatientswithoutanticoagulation,about50%,within3monthsanticoagulationtreatmentatleast3-12monthsofanticoagulationtreatmentPathophysiologyTheconsequencesofacutePEareprimarilyhaemodynamicandbecomeapparentwhen30–50%ofthepulmonaryarterialbedisoccludedbythromboemboli.Largeand/ormultipleembolimightabruptlyincreasepulmonaryvascularresistancetoalevelofafterloadwhichcannotbematchedbytherightventricle(RV).Suddendeath:Electormechanicaldissociationsyncopeand/orsystemichypotensionPathophysiologyPatientssurviving:activatethesympatheticsystemrestingpulmonaryflow,leftventricularfillingandoutput,Togetherwithsystemicvasoconstriction,RVcoronaryperfusionandthefunctionoftheRVSecondaryhaemodynamicdestabilizationmayoccur,usuallywithinfirst24–48h,recurrentemboliordeteriorationofRVfunctionincreasedRVmyocardialoxygendemandanddecreasedRVcoronaryperfusionRespiratoryinsufficiencyinPEispredominantlyaconsequenceofhaemodynamicdisturbances.SeverityofpulmonaryembolismPrincipalmarkersusefulforriskstratificationinacutepulmonaryembolismTable4Riskstratificationaccordingtoexpectedpulmonaryembolism-relatedearlymortalityrateTable5DiagnosisDiagnosis:probabilityX-rayandbloodgasanalysis:plate-likeatelectasis;pleuraleffusion;elevationofahemidiaphragm.PEisgenerallyassociatedwithhypoxaemia,butupto20%ofpatientswithPEhaveanormal(PaO2)andD(A-a)O2ECG:inversionofTwavesinleadsV1–V4,QRpatterninleadV1,classicS1O3T3,rightbundle-branchblock.suchchangesaregenerallyassociatedwiththemoresevereformsofPEandmaybefoundinrightventricularstrainofanycause.Insummary:clinicalsigns,symptomsandroutinelaboratorytestsdonotallowtheexclusionorconfirmationofacutePEbutincreasetheindexofitssuspicion.AssessmentofclinicalprobabilityClinicalpredictionrulersforPE:theWellsscoreandtherevisedGenevascoreAuxiliaryexaminationD-dimerultrasonographyVentilation–perfusionscintigraphyComputedtomographyPulmonaryangiographyEchocardiographyDiagnosticstrategiessuspectedhigh-riskPE:suspectednon-high-riskPE:DiagnosticstrategiesValidateddiagnosticcriteriafordiagnosingPEinpatientswithoutshockandhypotension(non-high-riskPE)accordingtoclinicalprobabilityRecommendations:diagnosisRecommendations:diagnosisRecommendations:diagnosisPrognosticassessmentClinicalassessmentofhaemodynamicstatusMarkersofrightventriculardysfunctionMarkersofmyocardialinjuryAdditionalriskmarkers(Table12)TreatmentHaemodynamicandrespiratorysupportThrombolysisSurgicalpulmonaryembolectomyPercutaneouscatheterembolectomyandfragmentationInitialanticoagulationObjective:preventdeathandrecurrenteventsUFHLMWHfondaparinuxanticoagulanttreatmentshouldbeconsideredinpatientswithsuspectedPEwhileawaitingdefinitivediagnosticconfirmation.aninitialcourseofheparininadditiontoVKAsUFHisgiven80U/kgasabolusinjectionfollowedbyinfusionattherateof18U/kg/hshouldbepreferredtofixeddosagesofheparin.Subsequentadjustedusing(aPTT)-based（table15）InitialanticoagulationTheaPTTshouldbemeasured4–6hafterthebolusinjectionandthen3haftereachdoseadjustment,oroncedailywhenthetargettherapeuticdosehasbeenreached.aPTTisnotaperfectmarkeroftheintensityoftheanticoagulanteffectofheparin.Therefore,itisnotnecessarytoincreasetheinfusionrateabove1667U/hprovidedtheanti-factorXaheparinlevelisatleast0.35IU/mL,eveniftheaPTTratioisbelowthetherapeuticrange.Initialanticoagulationanticoagulationwithunfractionatedheparin,LMWHorfondaparinuxshouldbeinitiatedwithoutdelayinpatientswithconfirmedPEandthosewithahighorintermediateclinicalprobabilityofPEwhilethediagnosticworkupisstillongoing.Exceptforpatientsathighriskofbleedingandthosewithsevererenaldysfunction,subcutaneousLMWHorfondapar-inuxratherthanintravenousunfractionatedheparinshouldbeconsideredforinitialtreatment.