近年来,肺栓塞患者的风险分层一直是大量研究的主题。当前的指南表明,为了鉴定可能从门诊治疗中受益的低风险患者和高危患者,他们应被送往医院,并且可能受益于更具侵略性的治疗形式[1]。This can be achieved by clinical examination alone using either an explicit risk stratification tool or a more empirical set of criteria [2-5]。通过生物标志物,超声心动图或螺旋计算机断层扫描评估的亚临床心肌损伤和右心室功能障碍也已被证明与肺栓塞患者的不良预后风险增加有关[6-8]。
B的研究ecattini等。[[9],发表在本期european Respiratory Journal,增强计算机断层扫描(CT)在肺栓塞患者的风险分层中的作用。使用对所有回顾性和前瞻性研究的系统综述和荟萃分析,评估CT对急性肺栓塞患者预后的作用,Becattini等。[[9] were able to demonstrate or to confirm that right ventricular dysfunction is associated with an increased risk of adverse outcome in patients with pulmonary embolism. Indeed, right ventricular dysfunction was associated with overall death at 1 and 3 months in all patients with pulmonary embolism and in clinically stable patients. Right ventricular dysfunction was also associated with the outcome of death due to pulmonary embolism. These results were observed for reconstructed four-chamber images and for transverse bi-dimensional images, suggesting that the former technique is not mandatory for the assessment of right ventricular dysfunction on spiral CT.
以前的work by the same group demonstrated high interobserver agreement (kappa-statistic 0.88) and diagnostic accuracy (area under the curve 0.86) of spiral CT for detecting right ventricular dysfunction, by using echocardiography as the reference standard [10]。一个lthough echocardiography can provide the same information on right ventricular dysfunction, it is not available in noncardiology departments, whereas spiral CT is more widely available and can provide clinicians with both diagnostic and prognostic information for patients with pulmonary embolism.
系统评价和荟萃分析提供的信息严重取决于分析中包括的原始研究的局限性。在大多数研究中,Becattini等。[[9], the results of spiral CT were not adjusted for clinical variables and biomarkers. Accordingly, these results do not demonstrate that spiral CT provides independent prognostic information to clinical findings and biomarkers. Previous studies suggest that right ventricular dysfunction diagnosed on echocardiography adds significant prognostic information to clinical findings and the pulmonary embolism severity index (PESI) [11,,,,12],但这尚未在所有研究中报告[13]。临床风险分层工具既反映肺栓塞的临床严重程度和潜在疾病,并且可能提供的信息与螺旋CT和生物标志物不同。
我们可以从这些发现中得出什么结论?从流行病学的角度来看,右心室功能障碍无疑与肺栓塞患者的死亡风险增加有关,但是如果螺旋CT为生物标志物和临床发现增加大量预后信息,那么问题仍然存在。
From a physiological point of view, the results reported by Becattini等。[[9] reinforce some rather old but pioneering data suggesting that the prognosis of pulmonary embolism is not related to the level of pulmonary vascular obstruction本身,,,,but to the consequences on the right ventricular function [14]。我ndeed, in a similar analysis conducted by the same group, pulmonary vascular obstruction was not associated with mortality in patients with pulmonary embolism [15]。
From a practical point of view, the evaluation of right ventricular dilation on transverse images provided by spiral CT is easy to perform. Right ventricular dilation is associated with an increased risk of adverse outcome and should prompt the measurement of cardiac biomarkers. Patients with both right ventricular dilation and increased blood levels of cardiac biomarkers belong to the intermediate-risk group as defined by the European Society of Cardiology [1]。our own recent, unpublished data suggest that thrombolytic treatment may decrease the rate of haemodynamic decompensation in these patients and may be considered when the bleeding risk is low. Conversely, the absence of right ventricular dilation on spiral CT is associated with a low rate of adverse outcome related to pulmonary embolism and these patients can benefit from early discharge, provided that no underlying condition requires hospitalisation. The question remains if right ventricular dysfunction should be measured in all patients with confirmed pulmonary embolism, or only in patients belonging to PESI class III or IV or with sPESI ≥1.
Footnotes
Conflict of interest: Disclosures can be found alongside the online version of this article atwww.www.qdcxjkg.com
- received2014年2月26日。
- 公认2014年3月3日。
- ©ERS 2014