肺血栓栓塞症预后因素分析
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摘要
目前,随着认识的增加、诊断技术的提高,肺血栓栓塞症(PTE)的发病率明显呈上升趋势。同时,大家对PTE预后的关注也越来越多,其预后差异较大,轻者可无明显症状,但治愈后有可能复发,严重者可发展成慢性血栓栓塞性肺动脉高压(CTEPH),甚至死亡,且病死率较高。因此,及时识别PTE的预后危险因素对改善患者预后具有重要意义。本文通过PubMed、CNKI等检索相关文献,就影响PTE预后的因素作一综述。影响PTE预后的因素多种多样:PTE预后与肺栓塞严重指数(PESI)评分系统、疾病危险分层、治疗方案选择及治疗并发症等因素密切相关,亦与血清标志物如BNP/NT-proBNP、肌钙蛋白和D-二聚体存在必然的联系;PESI评分系统是评估PTE预后最广泛有效的指标,其中高龄患者和合并恶性肿瘤患者预后不良事件发生率大大增加,可能是影响PTE预后的两大独立危险因素。对于临床上那些存在危险预后因素的PTE患者,应高度警惕,采取个体化治疗,加强对患者的规范化管理,从而改善预后,提高生存率。
With the increase of knowledge and the improvement of diagnostic techniques nowadays,the morbidity of pulmonary thromboembolism( PTE) is obviously on the rise. Moreover,a growing number of people are concerned about PTE prognosis,which shows great differences. It can be asymptomatic in less severe cases,but it may be recurrent after cure. In severe cases,it can develop into chronic thromboembolic pulmonary hypertension( CTEPH),or even death,with high case fatality rate. So promptly recognizing the risk factors of prognosis is of great significance in improving the prognosis of patients with PTE. Through retrieving literature from PubMed,CNKI and so on,this review focused on the factors affecting prognosis of PTE. Various factors affect the prognosis of PTE. The prognosis of PTE is closely relevant to PESI scoring system,PTE risk stratification,treatment options and complications of treatment. And it also has inevitable connection with serum markers such as BNP or NT-proBNP,troponin and D-dimer. PESI scoring system is the most widely and effectively used indicator to evaluate the prognosis of PTE,among which elder patients and patients with malignant tumor have more incidence rate of adverse events. So advanced age and malignant tumor may be independent risk factors which affect the prognosis of PTE. Clinically for those PTE patients with prognostic risk factors,we should be on high alert,adopt individualized treatment,and strengthen the standardized management of patients,thus improving the prognosis and increasing the survival rate.
With the increase of knowledge and the improvement of diagnostic techniques nowadays,the morbidity of pulmonary thromboembolism( PTE) is obviously on the rise. Moreover,a growing number of people are concerned about PTE prognosis,which shows great differences. It can be asymptomatic in less severe cases,but it may be recurrent after cure. In severe cases,it can develop into chronic thromboembolic pulmonary hypertension( CTEPH),or even death,with high case fatality rate. So promptly recognizing the risk factors of prognosis is of great significance in improving the prognosis of patients with PTE. Through retrieving literature from PubMed,CNKI and so on,this review focused on the factors affecting prognosis of PTE. Various factors affect the prognosis of PTE. The prognosis of PTE is closely relevant to PESI scoring system,PTE risk stratification,treatment options and complications of treatment. And it also has inevitable connection with serum markers such as BNP or NT-proBNP,troponin and D-dimer. PESI scoring system is the most widely and effectively used indicator to evaluate the prognosis of PTE,among which elder patients and patients with malignant tumor have more incidence rate of adverse events. So advanced age and malignant tumor may be independent risk factors which affect the prognosis of PTE. Clinically for those PTE patients with prognostic risk factors,we should be on high alert,adopt individualized treatment,and strengthen the standardized management of patients,thus improving the prognosis and increasing the survival rate.
引文
[1]Konstantinides SV,Torbicki A,Agnelli G,et al.2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism[J].Eur Heart J,2014,35(43):3033-3069.
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[3]Shapiro NL,Bhatt SH.Critical Review and Update on the Treatment of Acute and Chronic Pulmonary Embolism[J].J Pharm Pract,2016,29(1):35-45.
[4]Gong X,Duan Z,Yuan Y.Long-term prognosis and related factors towards patients with acute pulmonary thromboembolism[J].Int J Clin Exp Med,2015,8(5):7906-7913.
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[8]Dentali F,Riva N,Turato S,et al.Pulmonary embolism severity index accurately predicts long-term mortality rate in patients hospitalized for acute pulmonary embolism[J].J Thromb Haemost,2013,11(12):2103-2110.
[9]Heit JA.Predicting the risk of venous thromboembolism recurrence[J].Am J Hematol,2012,87(Suppl 1):S63-67.
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[11]Long B,Koyfman A.Current Controversies in Thrombolytic Use in Acute Pulmonary Embolism[J].J Emerg Med,2016,51(1):37-44.
[12]Ageno W,Gallus AS,Wittkowsky A,et al.Oral anticoagulant therapy:Antithrombotic Therapy and Prevention of Thrombosis,9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J].Chest,2012,141(2 Suppl):e44S-88S.
[13]Chatterjee S,Chakraborty A,Weinberg I,et al.Thrombolysis for pulmonary embolism and risk of all-cause mortality,major bleeding,and intracranial hemorrhage:a meta-analysis[J].JAMA,2014,311(23):2414-2421.
[14]Bertoletti L,Quenet S,Laporte S,et al.RIETE Investigators.Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease:data from the RIETE registry[J].Respir Res,2013,14(1):75.
[15]Eichinger S.Cancer associated thrombosis:risk factors and outcomes[J].Thromb Res,2016,140(Suppl 1):S12-17.
[16]谢衬梨,赵一菊,蔡良真,等.肺癌合并静脉血栓患者的临床特点及预后分析[J].中国现代药物应用,2015,9(15):33-34.
[17]Spirk D,Aujesky D,Stuck AK,et al.Clinical Outcomes of Venous Thromboembolism in Patients with and without Cancer:The SWIss Venous Thrombo Embolism Registry(SWIVTER)[J].Semin Thromb Hemost,2016,42(6):642-649.
[18]Lankeit M,Jimenez D,Kostrubiec M,et al.Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism[J].Eur Respir J,2014,43(6):1669-1677.
[19]张旭东.血浆B型尿钠肽与急性肺栓塞预后相关性的研究[J].中国现代医生,2012,50(19):1-3.
[20]Verschuren F,Bonnet M,Benoit MO,et al.The prognostic value of pro-B-Type natriuretic peptide in acute pulmonary embolism[J].Thromb Res,2013,131(6):e235-239.
[21]Bajaj A,Rathor P,Sehgal V,et al.Prognostic Value of Biomarkers in Acute Non-massive Pulmonary Embolism:A Systematic Review and Meta-analysis[J].Lung,2015,193(5):639-651.
[22]陈军,阮丽波,李芩.联合检测D-二聚体、心肌肌钙蛋白Ⅰ和纤维蛋白原对急性肺栓塞预后评估的意义[J].中国实用医药,2016,11(12):26-27.
[23]Hakemi EU,Alyousef T,Dang G,et al.The prognostic value of undetectable highly sensitive cardiac troponin I in patients with acute pulmonary embolism[J].Chest,2015,147(3):685-694.
[24]郭梦菲.肌钙蛋白对急性肺栓塞预后预测价值的Meta分析[D].武汉:华中科技大学,2013.
[25]Thielmann M,Pasa S,Wendt D,et al.Prognostic significance of cardiac troponin I on admission for surgical treatment of acute pulmonary embolism:a single-centre experience over more than 10 years[J].Eur J Cardiothorac Surg,2012,42(6):951-957.
[26]Walter T,Apfaltrer P,Weilbacher F,et al.Predictive value of highsensitivity troponin I and D-dimer assays for adverse outcome in patients with acute pulmonary embolism[J].Exp Ther Med,2013,5(2):586-590.
[27]宫小薇,袁雅冬.肺血栓栓塞症全因死亡相关因素的荟萃分析[J].中华医学杂志,2013,93(32):2534-2540.
[28]Becattini C,Lignani A,Masotti L,et al.D-dimer for risk stratification in patients with acute pulmonary embolism[J].J Thromb Thrombolysis,2012,33(1):48-57.
[29]Konstantinides SV,Barco S,Lankeit M,et al.Management of Pulmonary Embolism:An Update[J].J Am Coll Cardiol,2016,67(8):976-990.
[30]Kearon C,Akl EA,Comerota AJ,et al.Antithrombotic Therapy for VTE Disease:Antithrombotic Therapy and Prevention of Thrombosis,9th ed:American College of Chest Physicians Evidence Based Clinical Practice Guidelines[J].Chest,2012,141(2 Suppl):e419S-494S.
[31]Hao Q,Dong BR,Yue J,et al.Thrombolytic therapy for pulmonary embolism[J].Cochrane Database Syst Rev,2015(9):CD004437.
[32]Stein PD,Matta F.Thrombolytic therapy in unstable patients with acute pulmonary embolism:saves lives but underused[J].Am J Med,2012,125(5):465-470.
[33]Kline JA,Nordenholz KE,Courtney DM,et al.Treatment of submassive pulmonary embolism with tenecteplase or placebo:cardiopulmonary outcomes at 3 months:multicenter double-blind,placebo-controlled randomized trial[J].J Thromb Haemost,2014,12(4):459-468.
[34]Palareti G.Recurrent venous thromboembolism:what is the risk and how to prevent it[J].Scientifica(Cairo),2012,2012:391734.
[35]Klein SJ,Vedantham S.Acute deep vein thrombosis cases in the real world[J].Semin Intervent Radiol,2012,29(1):23-28.
[36]Kim NH,Delcroix M,Jenkins DP,et al.Chronic thromboembolic pulmonary hypertension[J].J Am Coll Cardiol,2013,62(25 Suppl):D92-99.
[37]Lang IM,Pesavento R,Bonderman D,et al.Risk factors and basic mechanisms of chronic thromboembolic pulmonary hypertension:a current understanding[J].Eur Respir J,2013,41(2):462-468.
[38]Mostafa A,Briasoulis A,Telila T,et al.Treatment of Massive or Submassive Acute Pulmonary Embolism With Catheter-Directed Thrombolysis[J].Am J Cardiol,2016,117(6):1014-1020.
[39]Stein PD,Matta F.Thrombolytic therapy in unstable patients with acute pulmonary embolism:saves lives but underused[J].Am J Med,2012,125(5):465-470.
[40]Witt DM,Clark NP,Martinez K,et al.Risk of thromboembolism,recurrent hemorrhage,and death after warfarin therapy interruption for intracranial hemorrhage[J].Thromb Res,2015,136(5):1040-1044.
[41]Tan Q,Chen Q,Niu Y,et al.Urokinase,a promising candidate for fibrinolytic therapy for intracerebral hemorrhage[J].J Neurosurg,2016:1-10.
[42]Witt DM,Delate T,Hylek EM,et al.Effect of warfarin on intracranial hemorrhage incidence and fatal outcomes[J].Thromb Res,2013,132(6):770-775.
[43]龚娟妮,翟振国,杨媛华,等.老年急性肺血栓栓塞症患者出血事件发生情况及影响因素[J].中华医学杂志,2015,95(44):3588-3592.
[44]闫建红,李保.肝素诱导血小板减少症的新进展[J].临床医药实践,2016,253(2):128-132.
[45]La Muraglia GM,Houbballah R,Laposata M.The identification and management of heparin-induced thrombocytopenia in the vascular patient[J].J Vasc Surg,2012,55(2):562-570.
[46]Linkins LA,Dans AL,Moores LK,et al.Treatment and prevention of heparin-induced thrombocytopenia:antithrombotic therapy and prevention of thrombosis,9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J].Chest,2012,141(2Suppl):e495S-530S.
[47]Lovecchio F.Heparin-induced thrombocytopenia[J].Clin Toxicol(Phila),2014,52(6):579-583.
[48]Cosmi B.Current management of heparin-induced thrombocytopenia[J].Expert Rev Hematol,2015,8(6):837-849.
[49]Kelton JG,Arnold DM,Bates SM.Nonheparin anticoagulants for heparin-induced thrombocytopenia[J].N Engl J Med,2013,368(8):737-744.
[2]Soares TH,de Bastos M,de Carvalho BV,et al.Prognostic value of computed tomographic pulmonary angiography and the pulmonary embolism severity index in patients with acute pulmonary embolism[J].Blood Coagul Fibrinolysis,2013,24(1):64-70.
[3]Shapiro NL,Bhatt SH.Critical Review and Update on the Treatment of Acute and Chronic Pulmonary Embolism[J].J Pharm Pract,2016,29(1):35-45.
[4]Gong X,Duan Z,Yuan Y.Long-term prognosis and related factors towards patients with acute pulmonary thromboembolism[J].Int J Clin Exp Med,2015,8(5):7906-7913.
[5]Kara H,Degirmenci S,Bayir A,et al.Pulmonary embolism severity index,age-based markers and evaluation in the emergency department[J].Acta Clin Belg,2015,70(4):259-264.
[6]Zhou XY,Ben SQ,Chen HL,et al.The prognostic value of pulmonary embolism severity index in acute pulmonary embolism:a meta-analysis[J].Respir Res,2012,13(1):111.
[7]Halim MU,Maruthappu M,Christian A,et al.The pulmonary embolism severity index:underused despite its clinical merits[J].J Emerg Med,2015,48(5):609.
[8]Dentali F,Riva N,Turato S,et al.Pulmonary embolism severity index accurately predicts long-term mortality rate in patients hospitalized for acute pulmonary embolism[J].J Thromb Haemost,2013,11(12):2103-2110.
[9]Heit JA.Predicting the risk of venous thromboembolism recurrence[J].Am J Hematol,2012,87(Suppl 1):S63-67.
[10]Keller K,Beule J,Coldewey M,et al.The risk factor age in normotensive patients with pulmonary embolism:Effectiveness of age in predicting submassive pulmonary embolism,cardiac injury,right ventricular dysfunction and elevated systolic pulmonary artery pressure in normotensive pulmonary[J].Exp Gerontol,2015,69(9):116-121.
[11]Long B,Koyfman A.Current Controversies in Thrombolytic Use in Acute Pulmonary Embolism[J].J Emerg Med,2016,51(1):37-44.
[12]Ageno W,Gallus AS,Wittkowsky A,et al.Oral anticoagulant therapy:Antithrombotic Therapy and Prevention of Thrombosis,9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J].Chest,2012,141(2 Suppl):e44S-88S.
[13]Chatterjee S,Chakraborty A,Weinberg I,et al.Thrombolysis for pulmonary embolism and risk of all-cause mortality,major bleeding,and intracranial hemorrhage:a meta-analysis[J].JAMA,2014,311(23):2414-2421.
[14]Bertoletti L,Quenet S,Laporte S,et al.RIETE Investigators.Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease:data from the RIETE registry[J].Respir Res,2013,14(1):75.
[15]Eichinger S.Cancer associated thrombosis:risk factors and outcomes[J].Thromb Res,2016,140(Suppl 1):S12-17.
[16]谢衬梨,赵一菊,蔡良真,等.肺癌合并静脉血栓患者的临床特点及预后分析[J].中国现代药物应用,2015,9(15):33-34.
[17]Spirk D,Aujesky D,Stuck AK,et al.Clinical Outcomes of Venous Thromboembolism in Patients with and without Cancer:The SWIss Venous Thrombo Embolism Registry(SWIVTER)[J].Semin Thromb Hemost,2016,42(6):642-649.
[18]Lankeit M,Jimenez D,Kostrubiec M,et al.Validation of N-terminal pro-brain natriuretic peptide cut-off values for risk stratification of pulmonary embolism[J].Eur Respir J,2014,43(6):1669-1677.
[19]张旭东.血浆B型尿钠肽与急性肺栓塞预后相关性的研究[J].中国现代医生,2012,50(19):1-3.
[20]Verschuren F,Bonnet M,Benoit MO,et al.The prognostic value of pro-B-Type natriuretic peptide in acute pulmonary embolism[J].Thromb Res,2013,131(6):e235-239.
[21]Bajaj A,Rathor P,Sehgal V,et al.Prognostic Value of Biomarkers in Acute Non-massive Pulmonary Embolism:A Systematic Review and Meta-analysis[J].Lung,2015,193(5):639-651.
[22]陈军,阮丽波,李芩.联合检测D-二聚体、心肌肌钙蛋白Ⅰ和纤维蛋白原对急性肺栓塞预后评估的意义[J].中国实用医药,2016,11(12):26-27.
[23]Hakemi EU,Alyousef T,Dang G,et al.The prognostic value of undetectable highly sensitive cardiac troponin I in patients with acute pulmonary embolism[J].Chest,2015,147(3):685-694.
[24]郭梦菲.肌钙蛋白对急性肺栓塞预后预测价值的Meta分析[D].武汉:华中科技大学,2013.
[25]Thielmann M,Pasa S,Wendt D,et al.Prognostic significance of cardiac troponin I on admission for surgical treatment of acute pulmonary embolism:a single-centre experience over more than 10 years[J].Eur J Cardiothorac Surg,2012,42(6):951-957.
[26]Walter T,Apfaltrer P,Weilbacher F,et al.Predictive value of highsensitivity troponin I and D-dimer assays for adverse outcome in patients with acute pulmonary embolism[J].Exp Ther Med,2013,5(2):586-590.
[27]宫小薇,袁雅冬.肺血栓栓塞症全因死亡相关因素的荟萃分析[J].中华医学杂志,2013,93(32):2534-2540.
[28]Becattini C,Lignani A,Masotti L,et al.D-dimer for risk stratification in patients with acute pulmonary embolism[J].J Thromb Thrombolysis,2012,33(1):48-57.
[29]Konstantinides SV,Barco S,Lankeit M,et al.Management of Pulmonary Embolism:An Update[J].J Am Coll Cardiol,2016,67(8):976-990.
[30]Kearon C,Akl EA,Comerota AJ,et al.Antithrombotic Therapy for VTE Disease:Antithrombotic Therapy and Prevention of Thrombosis,9th ed:American College of Chest Physicians Evidence Based Clinical Practice Guidelines[J].Chest,2012,141(2 Suppl):e419S-494S.
[31]Hao Q,Dong BR,Yue J,et al.Thrombolytic therapy for pulmonary embolism[J].Cochrane Database Syst Rev,2015(9):CD004437.
[32]Stein PD,Matta F.Thrombolytic therapy in unstable patients with acute pulmonary embolism:saves lives but underused[J].Am J Med,2012,125(5):465-470.
[33]Kline JA,Nordenholz KE,Courtney DM,et al.Treatment of submassive pulmonary embolism with tenecteplase or placebo:cardiopulmonary outcomes at 3 months:multicenter double-blind,placebo-controlled randomized trial[J].J Thromb Haemost,2014,12(4):459-468.
[34]Palareti G.Recurrent venous thromboembolism:what is the risk and how to prevent it[J].Scientifica(Cairo),2012,2012:391734.
[35]Klein SJ,Vedantham S.Acute deep vein thrombosis cases in the real world[J].Semin Intervent Radiol,2012,29(1):23-28.
[36]Kim NH,Delcroix M,Jenkins DP,et al.Chronic thromboembolic pulmonary hypertension[J].J Am Coll Cardiol,2013,62(25 Suppl):D92-99.
[37]Lang IM,Pesavento R,Bonderman D,et al.Risk factors and basic mechanisms of chronic thromboembolic pulmonary hypertension:a current understanding[J].Eur Respir J,2013,41(2):462-468.
[38]Mostafa A,Briasoulis A,Telila T,et al.Treatment of Massive or Submassive Acute Pulmonary Embolism With Catheter-Directed Thrombolysis[J].Am J Cardiol,2016,117(6):1014-1020.
[39]Stein PD,Matta F.Thrombolytic therapy in unstable patients with acute pulmonary embolism:saves lives but underused[J].Am J Med,2012,125(5):465-470.
[40]Witt DM,Clark NP,Martinez K,et al.Risk of thromboembolism,recurrent hemorrhage,and death after warfarin therapy interruption for intracranial hemorrhage[J].Thromb Res,2015,136(5):1040-1044.
[41]Tan Q,Chen Q,Niu Y,et al.Urokinase,a promising candidate for fibrinolytic therapy for intracerebral hemorrhage[J].J Neurosurg,2016:1-10.
[42]Witt DM,Delate T,Hylek EM,et al.Effect of warfarin on intracranial hemorrhage incidence and fatal outcomes[J].Thromb Res,2013,132(6):770-775.
[43]龚娟妮,翟振国,杨媛华,等.老年急性肺血栓栓塞症患者出血事件发生情况及影响因素[J].中华医学杂志,2015,95(44):3588-3592.
[44]闫建红,李保.肝素诱导血小板减少症的新进展[J].临床医药实践,2016,253(2):128-132.
[45]La Muraglia GM,Houbballah R,Laposata M.The identification and management of heparin-induced thrombocytopenia in the vascular patient[J].J Vasc Surg,2012,55(2):562-570.
[46]Linkins LA,Dans AL,Moores LK,et al.Treatment and prevention of heparin-induced thrombocytopenia:antithrombotic therapy and prevention of thrombosis,9th ed:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J].Chest,2012,141(2Suppl):e495S-530S.
[47]Lovecchio F.Heparin-induced thrombocytopenia[J].Clin Toxicol(Phila),2014,52(6):579-583.
[48]Cosmi B.Current management of heparin-induced thrombocytopenia[J].Expert Rev Hematol,2015,8(6):837-849.
[49]Kelton JG,Arnold DM,Bates SM.Nonheparin anticoagulants for heparin-induced thrombocytopenia[J].N Engl J Med,2013,368(8):737-744.