肺栓塞指南解读

1,2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism,2,2014vs(2000 or 2008),(1) Initial risk stratification(2) Thrombolytic treatment(3) New oral anticoagulants(4) Chronic thromboembolic pulmonary hypertension,3,Epidemiology,difficult to determine：remain asymptomatic diagnosis may be an incidental findingsudden death,4,Epidemiology,over 317 000 deaths were related to VTE in six countries of the European Union (with a total population of 454.4 million) in 2004: 34% presented with sudden fatal PE 59% were deaths resulting from PE that remained undiagnosed during life 7%of the patients who died early were correctly diagnosed with PE before death. (Cohen AT, Venousthromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98(4):756764.),5,Predisposing factors,surgery traumaimmobilizationpregnancyoral contraceptive use hormone replacement therapy cancer obesity infection and central venous lines,6,Pathophysiology,Acute PE interferes with circulation and gas exchangeRight ventricular (RV) failure is considered the primary cause of death in severe PE,7,Clinical classification of pulmonaryembolism severity,Replace “massive PE sub-massive PE submassive PE”,8,Diagnosis,Clinical presentation non-specific,9,Assessment of clinical probability,10,Assessment of clinical probability,11,D-dimer testing,the negative predictive value is highthe positive predictive value is low（cancer, inflammation, bleeding, trauma, surgery and necrosis）age-adjusted cut-offs (age x 10 mg/L above 50 years) increasing specificity from 3446% and sensitivity above 97%（Schouten HJ. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism:systematic review and meta-analysis. BMJ 2013;346:f2492）,12,D-dimer testing,13,Computed tomographic pulmonary angiography（CTPA）,14,Pulmonary angiography,gold standardrarely performed now used to guide percutaneous catheter-directed treatment of acute PE.Thrombi as small as 12 mm within the sub-segmental arteries can be visualized by DSA,15,Special imaging examination,Lung scintigraphyMagnetic resonance angiographyEchocardiography：RV pressure overload and dysfunctionCompression venous ultrasonography:DVT,16,Laboratory tests and biomarkers,(BNP) or N-terminal (NT)-proBNPtroponin I or -Tserum creatinine levels and glomerular filtration rateH-FABP,17,Diagnostic strategies,18,Diagnostic strategies,19,Prognostic assessment,20,Treatment in the acute phase,Haemodynamic support: 1 aggressive volume expansion is of no benefit and may even worsen RVfunction 2 use of vasopressors is necessary 1)Norepinephrine:hypotensive patients 2)dobutamine,dopamine:low cardiac index, and normal BP 3)Epinephrine(combines the beneficial norepinephrine and dobutamine) 4)inhalation of nitric oxide 5)levosimendan,21,Treatment in the acute phase,respiratory support:administration of oxygen:reversed hypoxaemiamechanical ventilation: 1)PEEP should be applied with caution 2)Low tidal volumes ( 6 mL/kg ) keep the end-inspiratory plateau pressure 30,22,Anticoagulation,acute PE: 1)The standard duration of anticoagulation should cover at least 3 months 2)unfractionated heparin (UFH) low molecular weight heparin (LMWH) fondaparinux 3)Parenteral heparin should overlap with the initiation of a vitamin K antagonist(over the first 510 days),23,Anticoagulation,high or intermediate clinical probability forPE: 1) parenteral anticoagulation should be initiated whilst awaiting the results of diagnostic tests 2) LMWH or fondaparinux are preferred over UFH for initial anticoagulation in PE, as they carry a lower risk of inducing major bleeding and heparin-induced thrombocytopenia (HIT). 3)UFH ：primary reperfusion serious renal impairment(creatinine clearance,30 mL/min) severe obesity,24,Anticoagulation,25,Anticoagulation,Vitamin K antagonists:warfarin UFH, LMWH, or fondaparinux should be continued for at least 5 days and until INR has been 2.03.0 for two consecutive days,26,Anticoagulation,New oral anticoagulants: Dabigatran达比加群 Rivaroxaban利伐沙班:单药治疗 Apixaban阿哌沙班:单药治疗 Edoxaban依杜沙班,27,Anticoagulation,28,Thrombolytic treatment,indication：1)PE with shock or hypotension (I B)2)intermediate-high risk PE to permit early detectionof haemodynamic decompensation (rescue reperfusion therapy)(I B)The optimal time window： 1）within 48 hours of symptom onset 2) be useful for 614 days of symptom onset,29,Thrombolytic treatment,30,other treatment,1) Surgical embolectomy: high-risk PE, and intermediate-high-risk PE, particularly if thrombolysis is contraindicated or has failed.(IC)2）Percutaneous catheter-directed treatment: an alternative to surgical pulmonary embolectomy for patients in whom full-dose systemic thrombolysis is contra