,急性肺栓塞诊疗指南及进展 Guidelines and Progress on the Diagnosis and Management of Acute Pulmonary Embolism,Southwest Hospital,何国祥 Prof. Guoxiang HE 第三军医大学西南医院 重庆市介入心脏病学研究所 Southwest Hospital The Third Military Medical University Chongqing Institute of Interventional Cardiology,Southwest Hospital,Update in 2010,中国急性肺血栓栓塞症诊断治疗专家共识,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,1、背景 2、临床评估 3、定量评估 4、治疗 抗凝 溶拴 手术 导管治疗 5、妊娠PE 6、非血栓PE,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,1、背景 2、临床评估 3、定量评估 4、治疗 抗凝 溶拴 手术 导管治疗 5、妊娠PE 6、非血栓PE,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,FIG 1. Venous thromboembolism (VTE)/100,000 population/year from 1990 through 1999.(Data from Stein et al.3-5),Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,FIG 2. Deep venous thrombosis (DVT)/100,000 population/year shown according to age for the year 1999.6,7 (Reprinted with permission.10),Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,FIG 3. Pulmonary embolism (PE)/100,000 population/year shown according to age for the year 1999. (Data from Stein et al.5,6) (Reprinted with permission.10),Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,FIG 12. Estimated case fatality rates for PE according to decades of age. (Reprinted with permission.23),Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,FIG 4. PE and DVT in children. (Data from Stein et al.7),Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,Major risk factors for venous thrombosis, Major surgery Orthopaedic surgery to lower limb/lower limb trauma History of previous venous thrombosis Cancer Pregnancy/puerperium Reduced mobility major illness with prolonged bed rest Age 70 years Thrombophilias: antithrombin deficiency protein C deficiency protein S deficiency antiphospholipid antibodies,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,1、背景 2、临床评估 3、定量评估 4、治疗 抗凝 溶拴 手术 导管治疗 5、妊娠PE 6、非血栓PE,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,TABLE 5. Electrocardiographic manifestations: patients without prior cardiac or pulmonary disease,Data from Stein et al.29,57 Reprinted with permission.10 Some patients had more than 1 abnormality.,Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,TABLE 6. Plain chest radiograph in patients with acute pulmonary embolism and no prior cardiopulmonary disease,Data are from Stein et al.29,63 Reprinted with permission.10 aAmong patients with a pleural effusion, 86% had only blunting of the costophrenic angle. None had a pleural effusion that occupied more than one third of a hemithorax. bProminent central pulmonary artery and decreased pulmonary vascularity.,Guidelines and Progress on the Diagnosis and Management of Acute PE,肺实质异常,肺不张/萎陷,肺实变,胸水,Southwest Hospital,FIGURE 2. V/QSPECT for the detection of pulmonary embolism,V/QSPECT thermal imaging coronal posterior sections in a female patient show multiple large pulmonary-ventilatory areas of mismatch that indicate pulmonary emboli that involve the upper and lower lobes of the right lung (white arrows). V/QSPECT, ventilation and perfusion single photon emission computed tomography.,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,FIG 19. Relative use of diagnostic imaging tests in patients hospitalized with PE from 1979 through 2006. V/Q, ventilation/perfusion; ANGIOS, pulmonary angiograms. (Reprinted with permission.10),Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,FIG 20. CT pulmonary angiogram showing PE in the right pulmonary artery.,Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,FIG 21. CT venous phase image showing right popliteal vein thrombosis (arrow).,Curr Probl Cardiol 2010;35:314-376,Guidelines and Progress on the Diagnosis and Management of Acute PE,Southwest Hospital,Three images from a single computed tomography pulmonary angiography (CTPA) study performed with a high clinical suspicion of pulmonary embolism (PE). Image 1 demonstrates a large PE in the proximal right pulmonary artery. Image 2 shows a significant concurrent pneumothorax. Image 3 demonstrates an RV/LV ratio 1 signifying significant right ventricular (RV) dysfunction. Together these images show the high utility of CTPA in diagnosis/exclusion of PE, diagnosis/exclusion of differential diagnoses, and i