课件：急性肺栓塞的诊治进展.ppt

* Several interesting observations have been made recently. One is that within the US, regional differences in the incidence of VTE are evident. Data from the National Hospital Discharge Survey, reported by Stein and colleagues is based on a sample of 8% of non-Federal general and specialty short-stay hospitals over a 23 year period from 1979-2001, The investigators identified a total of 2,741,000 pulmonary emboli, 6,475,000 DVT’s and 8,575,000 VTE episodes over the whole period. Rates of DVT and VTE were lower in the Western states (shown in red) than elsewhere, and PE was lower in West than elsewhere except Midwest. A number of factors might potentially contribute to this disparity. It is interesting to note that the West has a higher %age of Asian-Americans and Pacific Islanders (8.2%) than Midwest (1.6%), NE (3.2%) or South (1.7%), as depicted by the areas of denser purple. But Caucasians had less DVT, PE and VTE in West than elsewhere, and African-Americans and Caucasians had lower PE mortality rates than elsewhere. * 预防PTE-DVT的机械性措施：可计量压力的弹力袜（elastic stocking, ES）、间断充分压迫装置（intermittent pneumatic compression, IPC）可促使血管内皮纤维蛋白溶解，因此可用于高出血风险患者或作为在药物抗凝基础上的辅助预防措施。使用ES或IPC，可使普通外科患者DVT的患病率从20%-24%降至9%。对急性心肌梗死患者DVT预防的研究显示，使用ES侧下肢纤维蛋白原摄取描描异常率为0，未使用侧下肢为10%，两者差异有统计学意义（P=0.003）[22]。在681例缺血性卒中患者的非随机前瞻性研究中，小剂量肝素（low-dose unfractionated heparin, LDUH）联合ES、IPC组PTE-DVT发生率低于LDUH联合ES组[23]。 * 药物预防PTE-DVT：因静脉血栓主要由散在纤维蛋白和大量红细胞组成，血小板不是血栓的主要成分，因此预防PTE-DVT应以抗凝血酶药物为主，不主张单独使用抗血小板药如阿司匹林预防。最新的一些研究表明，对于急诊的内科学住院患者，PTE-DVT的预防用UFH5000IU，3次/d较2次/d更有效，但出血的危险性也相对增高[24]。在用LMWH与UFH预防PTE-DVT的对比研究中，LMWH的安全性更好，其预防效果与UFH5000IU，2次/d相似。在缺血性卒中、心力衰竭者，用LMWH预防PTE-DVT效果优于LDUH。对年龄小于40岁、无其他危险因素行外科小手术的低危患者，推荐早期活动，不需特殊预防措施。对有危险因素的小手术、年龄40-60岁或有危险因素的非大型手术的中度危险患者，推荐使用UFH5000IU，2次/d或LMWH≤3400IU/d。对年龄大于60岁或有危险因素的非大型手术患者，年龄大于40岁或有危险因素需大型手术的高危患者，推荐使用UFH5 000IU，3次/d或LMWH＞3 400IU/d。 * 对有多种危险因素、进行髋关节或膝关节成形术、髋部骨折或严重创伤、脊柱创伤的极高危患者，推荐选用戊聚糖钠、LMWH或维生素K拮抗剂，预防用药至少10d。大型妇科手术或开放性泌尿外科大手术，推荐UFH5 000 IU， 2次/d或3次/d。对充血性心力衰竭、严重呼吸系统疾