CLINICAL RISKS OF THROMBOLYTIC THERAPY
CLINICAL RISKS OF THROMBOLYTIC THERAPY
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DOI：
10.1016/0002-9149(92)91168-4
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发表时间：
1992-01-03
影响因子：
2.8
通讯作者：
SANE, DC
中科院分区：
文献类型：
--
作者：
CALIFF, RM;FORTIN, DF;SANE, DC
了解静脉溶栓治疗的临床风险对于选择合适的患者至关重要。主要风险可分为5大类：颅内出血、全身出血、免疫并发症、低血压和心肌破裂。虽然理论上存在血栓栓塞并发症的担忧，但很少发生。虽然心律紊乱在再灌注时更可能发生，但“再灌注心律失常”的临床意义很小。颅内出血是最具破坏性的并发症，在接受溶栓治疗的患者中发生率为0.2-1%。与增量风险相关的因素正在从大型临床试验中确定。全身性出血在没有严重血管穿刺的患者中并不常见，很少导致严重不良结局。免疫并发症-包括过敏反应，这是罕见的，免疫复合物疾病，这是更常见的-只发生与链激酶或药物与链激酶部分，包括阿尼普酶（茴香酰化纤溶酶原-链激酶激活剂复合物，APSAC）。低血压，这可以很容易地管理在大多数患者中，也更频繁地观察到链激酶和阿尼普酶。心肌破裂是晚期溶栓治疗的一种可能并发症，只有在考虑溶栓治疗的潜在获益的情况下，才能正确认识其临床风险。在许多情况下，被认为是并发症风险最高的个体患者也会从治疗中获益最多。正在进行的全球t-PA和链激酶利用（GUSTO）试验正在解决目前可用的出血风险数据提出的许多问题。考虑这个决策问题的一个范例。
Understanding the clinical risks of intravenous thrombolytic therapy is critical to appropriate patient selection. The major risks can be classified into 5 major categories: intracranial hemorrhage, systemic hemorrhage, immunologic complications, hypotension, and myocardial rupture. Although theoretical concern exists about thromboembolic complications, they rarely occur. Although cardiac rhythm disturbances are somewhat more likely to occur at the time of reperfusion, the clinical significance of "reperfusion arrhythmias" is minimal. Intracranial hemorrhage, the most devastating complication, occurs in 0.2-1% of patients treated with thrombolytic therapy. Factors associated with incremental risk are now being identified from large clinical trials. Systemic hemorrhage is uncommon in patients without major vascular punctures and seldom leads to serious adverse outcomes. Immunologic complications-including anaphylaxis, which is rare, and immune complex disease, which is more common-occur only with streptokinase or agents with a streptokinase moiety, including anistreplase (anisoylated plasminogen-streptokinase activator complex, APSAC). Hypotension, which can be managed easily in most patients, is also observed much more frequently with streptokinase and anistreplase. Myocardial rupture is increasingly being recognized as a possible complication of late thrombolysis.A proper perspective on clinical risk can only be gained in the context of potential benefit of therapy. In many cases individual patients considered to be at highest risk for complications also stand to gain the most from treatment. Many of the questions raised by currently available data about bleeding risk are being addressed in the ongoing Global Utilization of t-PA and Streptokinase (GUSTO) Trial. A paradigm for considering this decision making problem is presented.