Pulmonary embolism thrombolysis: broadening the paradigm for its administration.
Pulmonary embolism thrombolysis: broadening the paradigm for its administration.
复制标题
肺栓塞溶栓：扩大其给药范式。
作者：
S. Goldhaber
在过去的30年里，关于PE中适当溶栓的建议引发了争论和争议。有时，那些准备期刊研讨会或全国会议的人通过邀请PE溶栓的“主角”和“对手”在公开场合互相殴打，成功地活跃了他们的项目。这样的练习自然会让辩手只关注支持他们指定立场的观点。因此，观众必须面对两种极端的观点，而这两种观点很少重叠。相反，已经召开了共识会议，以获得专家意见，然后发布关于溶栓在PE管理中的最佳作用的指南。不幸的是，无论是辩论还是共识会议都无助于推动这一领域的发展，因为“带回家的信息”往往更多地受到某个特定个人的口才和权威的影响，而不是基于文献的证据。具有讽刺意味的是，当数据稀少，感兴趣的领域模糊不清时，人们往往最依赖书面或口头辩论形式和共识准则。
在考虑PE溶栓时，人们应该停下来，以便列举几个基本点，而不是被激烈的争论所淹没。首先，PE表现出广泛的敏锐度，并且在大小和生理效应上明显不同。因此，最佳管理策略应依赖于风险分层，而不是“一刀切”的治疗方法。1其次，PE患者通常粗略地分为血流动力学不稳定（收缩期动脉压<90 mm Hg）或“正常血流动力学”。然而，心脏病专家尤其应该进一步将患者分类为具有正常的全身动脉压加上正常的右心室功能或正常的全身动脉压加上右心室功能障碍。后一种人群，这是康斯坦丁尼德斯和同事们在本期《循环》中研究的重点，可能......
Recommendations for appropriate administration of thrombolysis in PE have sparked debate and controversy for the past 30 years. Sometimes, those preparing journal symposia or national meetings have successfully enlivened their projects by inviting a “protagonist” and “antagonist” of thrombolysis for PE to pummel each other in public. Such exercises naturally tend to make the debaters focus solely on points that support their assigned positions. As a result, the audience must contend with two extreme views that rarely overlap. In contrast, consensus conferences have been convened to obtain expert opinions and then to issue guidelines on the optimal role of thrombolysis in PE management. Unfortunately, neither debates nor consensus conferences help to advance the field very much because the “take home message” is often swayed more by the articulateness and authority of a particular individual than by literature-based evidence. Ironically, the written or oral debate format and consensus guidelines are often relied on the most when data are sparse and the field of interest is murky.
Instead of becoming immolated by the heat of argument, one should pause when considering PE thrombolysis so that several fundamental points can be enumerated. First, PEs present with a wide spectrum of acuity and differ markedly in size and physiological effects. Therefore, optimal management strategies should rely on risk stratification rather than a “one size fits all” approach to treatment.1 Second, PE patients are often cursorily dichotomized as having either hemodynamic instability (with a systolic arterial pressure <90 mm Hg) or “normal hemodynamics.” However, cardiologists especially should further categorize patients as having normal systemic arterial pressure plus normal right ventricular function or normal systemic arterial pressure plus dysfunction of the right ventricle. The latter population, which was the focus of the study by Konstantinides and colleagues2 in this issue of Circulation , may …