JAMA：急性肺栓塞

Abstract

Importance: Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US.

肺栓塞（PE）的特征是肺动脉血流阻塞，通常由下肢静脉的血栓形成。PE的发病率约为每年每10万人60-120例。在美国，每年约有6万至10万例患者死于肺栓塞。

Observations: PE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age <50 years, heart rate <100/min, an oxygen saturation level of > 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, >40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%).

对于出现急性胸痛、呼吸短促或晕厥的患者，应考虑观察 PE。诊断由胸部影像学检查确定。在收缩压至少为 90 mm Hg 的患者中，可以使用以下 3 个步骤来评估可能的 PE 患者：评估 PE 的临床概率、D-二聚体检测（如有指征）和胸部影像学检查（如有指征）。PE 的临床概率可通过结构化评分或临床格式塔进行评估。在 PE 概率小于 15% 的患者中，存在 8 种临床特征（年龄 <50 岁，心率 <100/min，氧饱和度水平> 94%）、近期无手术或创伤、既往无静脉血栓栓塞事件、无咯血、无单侧腿部肿胀和无雌激素使用）可识别 PE 风险极低且无需进一步检查的患者。在临床概率较低或中等的患者中，D-二聚体水平低于 500 ng/mL 与 PE 的检测后概率小于 1.85% 相关。在这些患者中，无需胸部影像学检查即可排除 PE。在 50 岁及以上的患者和 PE 可能性较低的患者中，D-二聚体阈值的进一步改善是可能的。PE 概率高（即 >40% 概率）的患者应进行胸部影像学检查，无需进行 D-二聚体检测。对于肺栓塞且收缩压为 90 mm Hg 或更高的患者，与肝素联合维生素 K 拮抗剂（例如华法林，然后单独使用华法林）相比，直接口服抗凝剂（如阿哌沙班、依度沙班、利伐沙班或达比加群）治疗 PE 并不劣效，出血率降低 0.6%。对于 PE 且收缩压低于 90 mm Hg 的患者，建议进行全身性溶栓，且死亡率绝对降低 1.6%（从 3.9% 降至 2.3%）。

Conclusions and relevance: In the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg.

在美国，PE每年影响约37万名患者，每年可能导致约6万至10万例死亡。一线治疗包括直接口服抗凝剂，如阿哌沙班、依度沙班、利伐沙班或达比加群，溶栓仅用于收缩压低于 90 mm Hg 的患者。