摘要目的 观察延迟溶栓治疗急性大面积肺血栓栓塞症(PTE)的临床疗效及安全性,探讨影响其疗效的因素.方法 回顾分析2009-2013年北京安贞医院呼吸科收治的病程＞14 d且接受溶栓治疗的急性大面积PTE患者(延迟溶栓组)的临床资料,与同期收治的病程≤14 d且接受溶栓治疗的急性大面积PTE患者(窗内溶栓组)进行比较,观察2组治疗前基本情况、基础疾病,治疗后1周的有效率和出血发生率,分析影响延迟溶栓治疗疗效的因素.共纳入患者62例,均经CTPA确诊,其中男28例,女34例,平均年龄(55.6±1.9)岁,窗内溶栓组32例,延迟溶栓组30例.结果 与窗内溶栓组[(7.2±0.6)d]比较,延迟溶栓组病程较长[(24.8±0.9)d,P ＜0.001],症状加重时间为(5.3±0.8)d,与窗内溶栓组[(55±4)mmHg,1 mmHg =0.133 kPa]比较,延迟溶栓组超声心动图肺动脉收缩压(SPAP)较高[(69 ±4) mmHg,P=0.016],两组年龄、性别、D-二聚体、CT肺动脉阻塞指数(CTI)、血B型脑钠肽(BNP)、心肌肌钙蛋白I(TNI)、PaCO2和PaO2检测结果差异均无统计学意义.治疗后1周有效率和出血发生率延迟溶栓组分别为77％和30％,窗内溶栓组分别为78％和25％,两组比较差异无统计学意义(P＞0.05).单因素分析显示延迟溶栓治疗有效组合并高血压病比例较高,年龄较大,PaO2较低(P＜0.05或＜0.01),logistic多因素回归分析未发现延迟溶栓治疗有效的预测因素(均P ＞0.05).结论 对于病程＞14d、新近症状加重且D-二聚体增高的急性大面积PTE(高危层),采取延迟溶栓治疗,其疗效和安全性与窗内溶栓治疗相当.影响延迟溶栓患者疗效的危险因素尚待进一步明确.

abstractsObjective To observe the efficacy and safety of delayed thrombolytic therapy on acute massive pulmonary thromboembolism (PTE) and discuss the influence factors.Methods From 2009 to 2013,the clinical data of patients with acute massive pulmonary thromboembolism were analyzed retrospectively.Patients with over 14-day duration and treated with thrombolytic therapy (delayed thrombolytic group) were compared with those within 14-day duration and treated with thrombolytic therapy (normal thrombolytic group) in the same period.General conditions before treatment,case history,efficacy and the incidence of bleeding after one-week treatment were collected.The influence factors of delayed thrombolytic therapy were analyzed.Results Sixty two cases were collected and divided into the normal thrombolytic group with 32 cases and the delayed thrombolytic group with 30 cases.Compared with the normal thrombolytic group,the delayed thrombolytic group had a longer duration [(24.8 ± 0.9) vs.(7.2 ±0.6)d,P ＜0.001],an aggravation time of (5.3 ±0.8) d,and higher systolic pulmonary arterial pressure (SPAP) [(69 ±4)vs.(55 ±4)mmHg,1 mmHg=0.133 kPa,P=0.016].Ages,genders,D-Dimmer,CT subpulmonic obstruction index (CTI),brain natriuretic peptide (BNP),cardiactroponinI (TnI),PaCO2 values and PaO2 values had no statistical difference between two groups.After one-week treatment,the efficacy and the incidence of bleeding was 78％ and 25％ respectively in normal thrombolytic group,while they were 77％ and 30％ respectively in delayed thrombolytic group,and there was no significantdifference between two groups (P ＞ 0.05).The single factor analysis showed that the delayed thrombolytic group had more patients with hypertension,were older and had a lower PaO2 (P ＜ 0.05 or 0.01).Multivariate logistic regression analysis did not find the predictors of delayed thrombolytic therapy (P ＞ 0.05).Conclusions For acute massive PTE patients with duration over 14 days,increased D-D and new exacerbation of symptoms,delayed thrombolytic therapy had the same efficacy with the normal thrombolytic therapy.The factors for predicting efficacy need further research.