肺栓塞溶栓与抗凝治疗的疗效及出血风险对比研究

摘要

Objective To compare the effect and bleeding risk of thrombolytic and anticoagulation treatment in patients with massive acute pulmonary thromboembolism (APTE). Methods Clinical data of 68 massive PTE patients admitted to our hospital between May 2009 and May 2011 were retrospectively reviewed. 41 patients were treated with 50 mg rtPA and 27 patients were treated with unfractionated heparin. All the patients were reexamined by 64-slice CT after receiving 2 day' s treatment. Logistic regression analysis and Wilcoxon rank-sum test were performed to compare the treatment effect and bleeding risk between thrombolytic and anticoagulation group, respectively. Results Compared to anticoagulation group, patients in thrombolytic group were younger ( P = 0. 026 ) and fewer had history of hypertension, coronary heart disease and atrial fibrillation (all P < 0. 05 ). Patients in thrombolytic group at admission had faster heart rate ( P < 0. 001) , higher serum D-dimer ( P = 0. 016 ) level, lower oxygen saturation ( P < 0. 001) and more had T-wave inversion in ECG lead V1-4 (P < 0. 001 ) than in anticoagulation group. Logistic regression analysis showed thrombolytic therapy was more effective (85. 4% ) than anticoagulation treatment (59. 3% ) ( OR = 6. 423, P = 0. 015). There was no statistic difference in bleeding risk between the two groups. Conclusions Thrombolytic therapy with 50 mg rtPA is more effective than anticoagulation treatment in patients with massive APTE and has similar bleeding risk.%目的 比较溶栓与抗凝治疗对解剖学大面积急性肺栓塞的疗效和出血风险有无差异.方法 回顾性分析2009年5月至2011年5月我院收治的解剖学大面积急性肺栓塞患者共68例的临床资料,全部采用普通肝素治疗2d,其中41例给予50 mg重组组织型纤溶酶原激活剂(rtPA)溶栓治疗(溶栓组),余27例仅用肝素治疗(抗凝组),2d后复查64排CT,应用Logistic回归分析与秩和检验分别比较溶栓与抗凝的疗效和出血风险差异.结果 溶栓组患者与抗凝组比较年龄[(62.0±10.7)岁比(67.8±9.3)岁,P=0.026]、高血压[39.0％(16/41)比70.4％(19/27),P=0.011]、冠心病[14.6％ (6/41)比37.0％(10/27),P=0.033]、心房颤动[2.4％(1/41)比22.2％(6/27),P=0.013]、不吸氧时指脉氧饱和度[(91.1％±4.0％)比(93.8％±2.8％),P＜0.001]均低于抗凝组；溶栓组患者就诊时心率[(91.5±15.9)次/min比(73.2 +13.0)次/min,P＜0.001]、D-二聚体[5.0(3.4,7.2) μg/ml比3.3(1.7,5.4) μg/ml,P=0.016]、V1～V4导联T波倒置比例[61.0％ (25/41)比14.8％ (4/27),P＜0.001]均高于抗凝组.溶栓组治疗有效率为85.4％(35/41),抗凝组为59.3％(16/27),应用Logistic回归分析校正上述混杂因素后,两组疗效差异具有统计学意义(OR=6.423,P=0.015).在出血并发症上溶栓与抗凝未表现出统计学差异.结论 采用50 mg rtPA溶栓治疗解剖学大面积急性肺栓塞效果良好,优于抗凝治疗,且不明显增加出血风险.