瑞替普酶溶栓治療中危急性肺血栓栓塞癥的臨床研究
發(fā)布時間：2018-09-11 13:20
【摘要】：背景隨著臨床醫(yī)師診斷意識的提高和診斷技術(shù)的發(fā)展，急性肺血栓栓塞癥(APTE)己經(jīng)成為我國常見的心血管疾病，APTE死亡率高，未治療的APTE死亡率高達30%。目前已得到臨床各科醫(yī)師的高度重視。溶栓和抗凝是APTE主要自勺治療方法，而APTE危險分層為中危的APTE患者(有右心室功能不全和/或心肌損傷的證據(jù)而血流動力學(xué)穩(wěn)定)是臺溶栓治療存在爭議，爭議的焦點是溶栓治療存在出血風(fēng)險。新一代的溶栓藥物瑞件炸酶(r-PA)，因具有纖維蛋白特異性強，對血小板無影響，引起出血不良反應(yīng)低，半衰期長，溶栓作用強，可靜脈推注給藥，使用方便等優(yōu)點。目前國內(nèi)關(guān)于中危APTE患者應(yīng)用r-PA溶栓治療的溶栓方案、臨床療效、預(yù)后影響及安全性方面的研究很少。 目的探討中危八PTE患者應(yīng)用r-PA溶栓治療的臨床療效、安全性；通過隨訪了解及評價患者的近期預(yù)后，為中危APTE患者的臨床治療提供依據(jù)。 方法 1.選擇2010月個2011年1月至2111年11月于安陽市人民醫(yī)院行雙源CT肺動脈造影(DSCT-PA)確診為APTE的住院患者45例，隨機分為兩組，其中溶栓組23例，單純抗凝組(簡稱抗凝組)22例，所有患者均符合2008歐洲心臟病協(xié)會(ESC)《APTE診斷治療指南》危險分層—中危APTE診斷標(biāo)準(zhǔn)。 2.溶栓組患者應(yīng)用r-PA(18mg)靜脈推注溶栓后，應(yīng)用低子量肝素(LMWH)和華法林抗凝治療，兩者重疊應(yīng)用3-5d,華法林服用至少3個月。抗凝組患者僅應(yīng)用LMWH和華法林抗凝治療，用法同溶栓組。同時觀察患者生命體征，監(jiān)測臨床指標(biāo)。3d后復(fù)曬心臟彩超及DSVT-PA. 3.以治愈、顯效、進步、無效、惡化和死亡6級判斷標(biāo)準(zhǔn)對患者進行療效評價，以治愈＋顯效＋進步為有效，計算有效率，以惡化＋死亡計算嚴(yán)重事件發(fā)生率，統(tǒng)計出血并發(fā)癥。 4.出院后隨訪3個月，統(tǒng)計患者出血．、復(fù)發(fā)、死亡等事件發(fā)生率。 5．應(yīng)用SPSS17.0統(tǒng)計學(xué)軟件進行數(shù)據(jù)分析，P0.05表示差異有統(tǒng)計學(xué)意義，P0.01表示差異有極顯著統(tǒng)計學(xué)意義。 結(jié)果 1.兩組患者患者般情況、基本病因比較無統(tǒng)計學(xué)差異(P0.05)。 2.兩組患者治療3d后，溶栓組呼吸困難，胸痛等臨床癥狀改善比抗凝組更明顯。兩組患者治療3d后肺栓寨面積(段數(shù))減小，PASP明顯下降，HR和RF明顯減慢，PaO2、PaCO2和SaO2亦明顯改善，差異有統(tǒng)計學(xué)意義護(P0.05或P0.01)；但抗凝組不如溶栓組差異顯著(P0.05)。 3.兩組患者治療3d后，溶栓組治愈率26.09%(6/23)高于抗凝組治愈率4.55%(1/22)，兩組比較有統(tǒng)計學(xué)差異(P=0.0460.05);濟栓組總有效率86.96%(20/23)高于抗凝組總有效率50.00%(11/22)，，兩組比較有極顯著統(tǒng)計差異(P=0.0070.01)；抗凝組惡化3例(13.63%)，給予補救性濟栓治療后癥狀緩解，康復(fù)出院，死亡1例(4.55%)，抗凝組嚴(yán)垂事件發(fā)生率18.18%(4/22)，濟栓組無惡化和死亡份病例，兩組嚴(yán)重事件發(fā)生率比較差異有統(tǒng)計學(xué)意義(P=0.0320.05)。 4.兩組患者治療3d后各有2例輕度出血,出血生生率分別為8.70%和9.09%,兩組均無嚴(yán)重出血事件。兩組出血發(fā)生率比較無統(tǒng)計學(xué)差異(P=0.9630.05)。 5.從入院治療到3個朋隨訪結(jié)束，抗凝組惡化3例(13.64%)、復(fù)發(fā)1例(4.55%)、死亡1例(4.55%)，嚴(yán)重事件發(fā)生率22,72%(5/22)，溶栓組無嚴(yán)重事件(惡化、復(fù)發(fā)和死亡)發(fā)生，兩組嚴(yán)重事件發(fā)生率比較有統(tǒng)計學(xué)意義(P=0.0150.05)；抗凝組輕度出血2例(9.09%)，溶栓組輕度出血3例(13.04%)，兩組均無嚴(yán)重出血病例，兩組總出血發(fā)生率比較無統(tǒng)計學(xué)差異(P=0.6730.05)；溶栓組事件發(fā)生率86.96%(20/23)高于抗凝組無事件發(fā)生率68.18%(15/22)，兩組比較無統(tǒng)計學(xué)差異(P=0.1300.05). 結(jié)論 1.中危APTE患者應(yīng)用r-PA溶栓治療與單純抗凝治療相比可迅速改善患者的臨床癥狀，深解血栓，改善肺血流動力學(xué)，糾正有心室功能。 2.中危APTE(?)應(yīng)用r-PA溶栓治療與單純抗凝治療相比不僅治愈率高,總有效率高,而且可降低近期嚴(yán)重事件發(fā)生率(惡化+復(fù)發(fā)十死亡)：而出血風(fēng)險并未增加。 3.r-PA溶栓治療中,危APTE安全有效,r-PA溶栓方案在中危APTE治療上值得臨床推廣
[Abstract]:BACKGROUND With the improvement of clinicians'diagnostic awareness and the development of diagnostic techniques, acute pulmonary thromboembolism (APTE) has become a common cardiovascular disease in China. The mortality rate of APTE is high, and that of untreated APTE is as high as 30%. Thrombolytic therapy is controversial in APTE patients with moderate risk stratification (with evidence of right ventricular dysfunction and/or hemodynamic stability due to myocardial injury). The focus of controversy is the risk of bleeding in thrombolytic therapy. There are few studies on the clinical efficacy, prognosis and safety of r-PA thrombolytic therapy for moderate-risk APTE patients.
Objective To investigate the clinical efficacy and safety of r-PA thrombolysis in the treatment of moderate-risk patients with PTE.
Method
1. Forty-five hospitalized patients with APTE diagnosed by DSCT-PA in Anyang People's Hospital from January 2011 to November 2011 were randomly divided into two groups: thrombolytic group (23 cases) and anticoagulant group (22 cases). All patients met the risk score of Euro Heart Association (ESC)< APTE Diagnostic and Therapeutic Guidelines > and all patients were in accordance with the risk score. The diagnostic criteria for intermediate risk APTE.
2. Thrombolytic group was treated with r-PA (18mg) intravenous thrombolysis, low-dose heparin (LMWH) and warfarin anticoagulant therapy, the two overlap for 3-5 days, warfarin for at least 3 months. The anticoagulant group was treated with LMWH and warfarin anticoagulant therapy only, the use of the same thrombolytic group. At the same time, the vital signs of patients were observed and the clinical indicators were monitored. Color Doppler ultrasound and DSVT-PA.
3. Evaluate the curative effect of the patients according to the criteria of cure, marked effect, progress, inefficiency, deterioration and death, and calculate the effective rate with the criterion of cure + marked effect + progress, calculate the incidence of serious events with the criterion of deterioration + death, and count the complications of bleeding.
4. the patients were followed up for 3 months after discharge, and the incidence of bleeding, recurrence and death were recorded.
5. Statistical software SPSS17.0 was used to analyze the data. The difference between P 0.05 and P 0.01 was statistically significant.
Result
1. there was no statistically significant difference between the two groups in terms of patients' condition and underlying causes (P0.05).
2. After 3 days of treatment, the clinical symptoms such as dyspnea and chest pain in the thrombolytic group were improved more significantly than those in the anticoagulant group. Significant (P0.05).
3. After 3 days of treatment, the cure rate of thrombolysis group was 26.09% (6/23) higher than that of anticoagulation group (4.55% (1/22), there was significant difference between the two groups (P = 0.0460.05); the total effective rate of Jishuan group was 86.96% (20/23) higher than that of anticoagulation group (50.00% (11/22), there was significant difference between the two groups (P = 0.0070.01); the deterioration of anticoagulation group was 3 (13.63%) and the treatment was given. After treatment, the symptoms were relieved, and one patient was discharged from hospital. The incidence of severe droop was 18.18% (4/22) in anticoagulant group. There was no deterioration or death in the Jishuan group. The incidence of severe events between the two groups was statistically significant (P = 0.0320.05).
4. There were 2 cases of mild hemorrhage in each group 3 days after treatment. The incidence of hemorrhage was 8.70% and 9.09% respectively. There was no serious hemorrhage in both groups. There was no significant difference in the incidence of hemorrhage between the two groups (P=0.9630.05).
5. From hospitalization to the end of follow-up, 3 cases (13.64%) deteriorated in anticoagulation group, 1 case (4.55%) recurred, 1 case (4.55%) died, the incidence of serious events was 22.72% (5/22), no serious events (deterioration, recurrence and death) occurred in thrombolysis group, the incidence of serious events was statistically significant between the two groups (P = 0.0150.05); 2 cases (9.09%) in anticoagulation group, and 2 cases (9.09%) in thrombolysis group. There were 3 cases (13.04%) with mild hemorrhage in the thrombolytic group and 68.18% (15/22) with no severe hemorrhage in the anticoagulant group.
conclusion
1. Compared with anticoagulant therapy alone, r-PA thrombolytic therapy can rapidly improve the clinical symptoms, deep thrombolysis, improve pulmonary hemodynamics and correct ventricular function.
2. Medium-risk APTE (?) Thrombolytic therapy with r-PA is not only more effective than anticoagulant therapy, but also can reduce the incidence of recent serious events (deterioration + recurrence of 10 deaths): and the risk of bleeding did not increase.
In 3.r-PA thrombolytic therapy, APTE is safe and effective. R-PA thrombolysis regimen is worthy of clinical promotion in the treatment of APTE.
【學(xué)位授予單位】：新鄉(xiāng)醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R563.5
本文編號：2236800
[Abstract]:BACKGROUND With the improvement of clinicians'diagnostic awareness and the development of diagnostic techniques, acute pulmonary thromboembolism (APTE) has become a common cardiovascular disease in China. The mortality rate of APTE is high, and that of untreated APTE is as high as 30%. Thrombolytic therapy is controversial in APTE patients with moderate risk stratification (with evidence of right ventricular dysfunction and/or hemodynamic stability due to myocardial injury). The focus of controversy is the risk of bleeding in thrombolytic therapy. There are few studies on the clinical efficacy, prognosis and safety of r-PA thrombolytic therapy for moderate-risk APTE patients.
Objective To investigate the clinical efficacy and safety of r-PA thrombolysis in the treatment of moderate-risk patients with PTE.
Method
1. Forty-five hospitalized patients with APTE diagnosed by DSCT-PA in Anyang People's Hospital from January 2011 to November 2011 were randomly divided into two groups: thrombolytic group (23 cases) and anticoagulant group (22 cases). All patients met the risk score of Euro Heart Association (ESC)< APTE Diagnostic and Therapeutic Guidelines > and all patients were in accordance with the risk score. The diagnostic criteria for intermediate risk APTE.
2. Thrombolytic group was treated with r-PA (18mg) intravenous thrombolysis, low-dose heparin (LMWH) and warfarin anticoagulant therapy, the two overlap for 3-5 days, warfarin for at least 3 months. The anticoagulant group was treated with LMWH and warfarin anticoagulant therapy only, the use of the same thrombolytic group. At the same time, the vital signs of patients were observed and the clinical indicators were monitored. Color Doppler ultrasound and DSVT-PA.
3. Evaluate the curative effect of the patients according to the criteria of cure, marked effect, progress, inefficiency, deterioration and death, and calculate the effective rate with the criterion of cure + marked effect + progress, calculate the incidence of serious events with the criterion of deterioration + death, and count the complications of bleeding.
4. the patients were followed up for 3 months after discharge, and the incidence of bleeding, recurrence and death were recorded.
5. Statistical software SPSS17.0 was used to analyze the data. The difference between P 0.05 and P 0.01 was statistically significant.
Result
1. there was no statistically significant difference between the two groups in terms of patients' condition and underlying causes (P0.05).
2. After 3 days of treatment, the clinical symptoms such as dyspnea and chest pain in the thrombolytic group were improved more significantly than those in the anticoagulant group. Significant (P0.05).
3. After 3 days of treatment, the cure rate of thrombolysis group was 26.09% (6/23) higher than that of anticoagulation group (4.55% (1/22), there was significant difference between the two groups (P = 0.0460.05); the total effective rate of Jishuan group was 86.96% (20/23) higher than that of anticoagulation group (50.00% (11/22), there was significant difference between the two groups (P = 0.0070.01); the deterioration of anticoagulation group was 3 (13.63%) and the treatment was given. After treatment, the symptoms were relieved, and one patient was discharged from hospital. The incidence of severe droop was 18.18% (4/22) in anticoagulant group. There was no deterioration or death in the Jishuan group. The incidence of severe events between the two groups was statistically significant (P = 0.0320.05).
4. There were 2 cases of mild hemorrhage in each group 3 days after treatment. The incidence of hemorrhage was 8.70% and 9.09% respectively. There was no serious hemorrhage in both groups. There was no significant difference in the incidence of hemorrhage between the two groups (P=0.9630.05).
5. From hospitalization to the end of follow-up, 3 cases (13.64%) deteriorated in anticoagulation group, 1 case (4.55%) recurred, 1 case (4.55%) died, the incidence of serious events was 22.72% (5/22), no serious events (deterioration, recurrence and death) occurred in thrombolysis group, the incidence of serious events was statistically significant between the two groups (P = 0.0150.05); 2 cases (9.09%) in anticoagulation group, and 2 cases (9.09%) in thrombolysis group. There were 3 cases (13.04%) with mild hemorrhage in the thrombolytic group and 68.18% (15/22) with no severe hemorrhage in the anticoagulant group.
conclusion
1. Compared with anticoagulant therapy alone, r-PA thrombolytic therapy can rapidly improve the clinical symptoms, deep thrombolysis, improve pulmonary hemodynamics and correct ventricular function.
2. Medium-risk APTE (?) Thrombolytic therapy with r-PA is not only more effective than anticoagulant therapy, but also can reduce the incidence of recent serious events (deterioration + recurrence of 10 deaths): and the risk of bleeding did not increase.
In 3.r-PA thrombolytic therapy, APTE is safe and effective. R-PA thrombolysis regimen is worthy of clinical promotion in the treatment of APTE.
【學(xué)位授予單位】：新鄉(xiāng)醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R563.5
【參考文獻】
相關(guān)期刊論文 前10條
1 葉蕾;張榮華;;小劑量尿激酶加序貫抗凝治療次大面積肺栓塞25例療效評價[J];重慶醫(yī)學(xué);2010年07期
2 田寶石;董士民;李俠;張新顏;張愛東;董運芳;;注射用瑞替普酶治療肺血栓栓塞癥23例分析[J];河北醫(yī)藥;2006年03期
3 史旭波;胡大一;;新型抗凝藥物研究展望[J];臨床薈萃;2008年02期
4 張雙月;王雪青;卞秋武;孟曉京;馬利祥;劉曉媛;;半量瑞替普酶溶栓治療75歲以上急性心肌梗死療效及安全性比較[J];臨床心血管病雜志;2009年12期
5 袁曉靜;;注射用喜炎平[J];齊魯藥事;2006年07期
6 張克良;徐淑麗;陳曉剛;;半量瑞替普酶并低分子肝素溶栓治療急性下壁心肌梗死的安全性與有效性研究[J];實用醫(yī)學(xué)雜志;2011年05期
7 荊志成;;肺動脈血栓栓塞癥的臨床表現(xiàn)[J];中國社區(qū)醫(yī)師;2006年22期
8 楊京華;梁瑛;;急性肺血栓栓塞癥不同溶栓治療方案的臨床觀察[J];心肺血管病雜志;2008年01期
9 方保民;;重視肺血栓栓塞癥合并冠心病的診斷和治療[J];中國心血管雜志;2008年03期
10 瑞替普酶(派通欣)Ⅱ期臨床試驗協(xié)作組;注射用瑞替普酶(派通欣)治療急性心肌梗死有效性及安全性臨床研究[J];中國心血管病研究雜志;2004年03期
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