Risk stratification and management of acute pulmonary embolism
Risk stratification and management of acute pulmonary embolism
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DOI：
10.1182/asheducation-2016.1.404
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发表时间：
2016-12-01
影响因子：
3
通讯作者：
Agnelli, Giancarlo
中科院分区：
文献类型：
--
作者：
Becattini, Cecilia;Agnelli, Giancarlo
近年来，急性肺栓塞患者的临床管理正在迅速变化。这些患者的临床管理策略的范围不断扩大，需要有效的风险分层工具。死亡风险低的患者可能是家庭治疗或提前出院的候选人。具有高阴性预测值的临床模型已被验证，可用于选择死亡风险低的患者。在一项主要研究和几项荟萃分析中，血流动力学稳定患者的溶栓与严重出血并发症或颅内出血的不可接受的高风险相关。因此，休克或持续性低血压的存在仍然是选择溶栓治疗候选人的标准。早期血运重建的介入手术应保留给选定的患者，直到获得进一步的证据。在急性肺栓塞患者的急性期管理中，插入腔静脉滤器预期无临床优势。在急性肺栓塞患者中，与常规抗凝治疗相比，固定剂量的直接口服抗凝治疗（无实验室监测）显示出相似的疗效（比值比[OR]，0.89; 95%置信区间[CI]，0.70-1.12）和安全性（OR，0.89; 95% CI，0.77-1.03）。基于这些结果及其实用性，直接口服抗凝剂是治疗大多数急性肺栓塞患者的首选药物。
The clinical management of patients with acute pulmonary embolism is rapidly changing over the years. The widening spectrum of clinical management strategies for these patients requires effective tools for risk stratification. Patients at low risk for death could be candidates for home treatment or early discharge. Clinical models with high negative predictive value have been validated that could be used to select patients at low risk for death. In a major study and in several meta-analyses, thrombolysis in hemodynamically stable patients was associated with unacceptably high risk for major bleeding complications or intracranial hemorrhage. Thus, the presence of shock or sustained hypotension continues to be the criterion for the selection of candidates for thrombolytic treatment. Interventional procedures for early revascularization should be reserved to selected patients until further evidence is available. No clinical advantage is expected with the insertion of a vena cava filter in the acute-phase management of patients with acute pulmonary embolism. Direct oral anticoagulants used in fixed doses without laboratory monitoring showed similar efficacy (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.70-1.12) and safety (OR, 0.89; 95% CI, 0.77-1.03) in comparison with conventional anticoagulation in patients with acute pulmonary embolism. Based on these results and on their practicality, direct oral anticoagulants are the agents of choice for the treatment of the majority of patients with acute pulmonary embolism.