关于次大面积肺栓塞伴右心功能不全的溶栓问题？

liugang_sz

With regard to thrombolysis in the management of submassive and massive pulmonary embolism, which of the following statements are correct?

a. Right ventricular dysfunction on echo is a relative contraindication to thrombolysis.

b. Elderly patients are significantly more likely to have a major bleed with thrombolysis for pulmonary embolism compared with anticoagulation only.

c. Thrombolysis for pulmonary embolism requires an interventional radiologist for delivery.

d.There is no evidence for a mortality benefit of thrombolysis compared with therapeutic anticoagulation alone.

e. There are no large randomised controlled trials studying thrombolysis in this patient group.

50 F, T, F, F, F  The last few years has seen the publication of several trials regarding thrombolysis in acute submassive and massive pulmonary embolism (PE). The term ‘submassive’ implies preserved blood pressure and peripheral perfusion but with evidence of right heart strain. As the literature emerges our understanding of risk and benefit in this challenging condition increases. At recent meta-analysis, a comparison of mortality rates for those patients managed with thrombolysis versus anticoagulation alone suggests a significant reduction in favour of thrombolysis, from 3.89% to 2.17% (number needed to treat [NNT] of 59). This figure is lower than that quoted in many registries and may reflect exclusion criteria for entry into the trials considered. Although this result was significant, the high NNT reminds us that the overall mortality without thrombolysis is actually quite low. Coupled to this high NNT is the unfortunate association with major bleeding. This is markedly increased with thrombolysis in those patients over the age of 65, with an event rate approaching 13% and an odds ratio of 3.10 (95% CI 2.10-4.56) when compared to anticoagulation alone. Interestingly, no significant increase in major bleeding rates is reported with thrombolysis in the age group<65.

Most of the evidence concerning the efficacy of thrombolysis for pulmonary embolism concerns peripherally administered thrombolytic agents; while some studies have examined catheter-directed thrombolysis, this is not a current standard of care. The presence of right ventricular dysfuction is a marker of haemodynamic compromise that partly defines submassive pulmonary embolism; in its absence thrombolysis should not generally be administered as the degree of haemodynamic disturbance (and therefore clinical risk of mortality) is not high enough to justify the risks of the therapy (number needed to harm of 18 for major bleeding).

Half standard dose thrombolysis is an emerging therapy supported by the MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis) trial data. This study recently suggested a benefit in reduction of pulmonary hypertension after >2 years of follow-up and a non-significant trend towards reduced early mortality with low-dose thrombolytics in submassive PE. In addition, no increase in the rate of major bleeding was seen between groups. However, these are data from a single-centre trial in need of validation and unsuitable for general recommendation at present.

Overall, there is ongoing debate over the efficacy of thrombolysis in patients with submassive pulmonary embolism, and thrombolysis is not at present advocated for such patients in the most recent European guidelines.

The presence of right ventricular dysfuction is a marker of haemodynamic compromise that partly defines submassive pulmonary embolism;既然次大面积肺栓塞的右室功能不全本来就是定义的一部分，那为什么不能溶栓呢？上面一段已经说了除了老年人，溶栓的死亡率小于抗凝啊

At recent meta-analysis, a comparison of mortality rates for those patients managed with thrombolysis versus anticoagulation alone suggests a significant reduction in favour of thrombolysis, from 3.89% to 2.17%这句话是不是说溶栓的死亡率低呢？如果是的话，D为啥不对呢

liugang_sz

At recent meta-analysis, a comparison of mortality rates for those patients managed with thrombolysis versus anticoagulation alone suggests a significant reduction in favour of thrombolysis, from 3.89% to 2.17%这句话是不是说溶栓的死亡率低呢？如果是的话，D为啥不对呢

liugang_sz

大约翻译了一下，不知道对错

关于次大块和大块肺栓塞治疗中的溶栓治疗，以下哪项陈述是正确的？

a. 超声回声时右心功能不全是溶栓的相对禁忌症。

b 与仅抗凝治疗相比，老年患者更容易出现肺栓塞溶栓严重出血。

C。 肺栓塞的溶栓需要介入放射科医生进行。

d。与单独使用治疗性抗凝剂相比，没有证据表明溶栓治疗具有死亡率益处。

e 没有大型随机对照试验来研究该患者组的溶栓治疗。

F，T，F，F，F最近几年已经发表了几项关于急性次大块和大块肺栓塞（PE）溶栓的试验。 术语“次大块”意味着保持血压和外周灌注，但具有右心脏劳损的证据。 随着文献的出现，我们在这一具有挑战性的条件下对风险和收益的理解增加。 在最近的荟萃分析中，单独使用溶栓治疗与单独使用抗凝治疗的患者的死亡率比较表明溶栓治疗的更有效，死亡率从3.89％降至2.17％（需要治疗[NNT]为59）。 这一数字低于许多注册管理机构的数据，可能反映了进入所考虑审判的排除标准。 虽然这个结果是显着的，但高NNT提醒我们，没有血栓溶解的总体死亡率实际上相当低。 加上这个高NNT是与大出血不幸的关联。  65岁以上患者溶栓治疗后这一现象明显增加，事件发生率接近13％，与单独抗凝治疗相比，优势比为3.10（95％CI 2.10-4.56）。 有趣的是，<65岁年龄组溶栓治疗的主要出血发生率没有显着增加。

关于溶栓治疗肺栓塞的疗效的大多数证据都是外周施用的血栓溶解剂; 虽然一些研究已经检查了导管引导的溶栓治疗，但这不是目前的治疗标准。 右心室功能障碍的存在是血流动力学损害的一个标志，也是亚大块肺栓塞定义的一部分; 在不存在溶栓时，通常不应该进行溶栓治疗，因为血液动力学紊乱的程度（因此临床死亡风险）不够高，不足以证明治疗的必要。

半标准剂量溶栓是由MOPETT（用溶栓治疗的中度肺栓塞）试验数据支持的新兴疗法。 这项研究最近表明，在大于2年的随访中减少肺动脉高压的益处以及在亚大量PE中低剂量溶栓剂降低早期死亡率的非显着趋势。 此外，各组之间未见大出血发生率的增加。 然而，这些数据来自单一中心试验，需要进行验证，目前不适合一般性推荐。

总体而言，目前关于亚大块肺栓塞患者溶栓治疗疗效的争论不断，目前在欧洲最新的指南中并不支持溶栓治疗。