小结
定义
病史和体格检查
关键诊断因素
- 存在的危险因素
- 胸痛
- 呼吸困难
- 呼吸急促
- 晕厥先兆或晕厥
- 低血压（收缩压＜90 mmHg）
其他诊断因素
- 恐惧感
- 咳嗽
- 心动过速
- 发热
- 单侧小腿肿胀/压痛
- 咯血
- 颈静脉压升高。
- 胸骨隆起
- 肺动脉瓣处 S2 音亢进
危险因素
- 年龄增长
- 深静脉血栓形成 (DVT) 诊断
- 肥胖 (BMI ≥29 kg/m²)
- 近 2 个月内有手术史
- 卧床休息＞5 日
- 既往有静脉血栓栓塞病史
- 静脉血栓栓塞 (VTE) 家族史
- 恶性肿瘤活跃期
- 吸烟
- 慢性阻塞性肺疾病 (COPD)
- 有近期外伤或骨折病史
- 充血性心力衰竭 (CHF)
- 中心静脉置管
- 妊娠/产后
- 静脉曲张
- 近期乘坐飞机旅行
- 自然流产史
- 近期急性心肌梗死
- 脓毒症
- 近期输血史
- 复方激素避孕
- 口服激素替代治疗 (HRT)
- 下肢瘫痪
- 炎症性肠病
- 肾病综合征
- 白塞病
- 高同型半胱氨酸血症
- 费城染色体阴性的骨髓增殖性肿瘤
- 凝血因子 V Leiden 突变
- 凝血酶原 G20210A 突变
- 抗凝血酶缺乏
- 蛋白 C 缺陷
- 蛋白 S 缺陷
- 抗磷脂抗体综合征
诊断性检查
首要检查
- Wells 量表/Geneva 评分
- 多排螺旋 CT 肺动脉造影 (CTPA)
- 通气与血流灌注比值 (V/Q) 扫描
- 凝血功能检查
- 尿素和肌酐
- 全血细胞计数 (FBC）
- 肺栓塞排除标准 (PERC)
- D-二聚体检测
需考虑的检查
- 胸部 X 线检查 (CXR)
- 磁共振 (MR) 血管造影术
- 肺血管造影术
- 心电图 (ECG)
- 动脉血气 (arterial blood gas, ABG)分析
- 易栓症筛查
- 超声检查
新兴检查
- 脑利钠肽 (BNP)、N 末端脑钠肽前体 (NT-proBNP)、心型脂肪酸结合蛋白 (H-FABP)
治疗流程
高风险（大面积 PE 或 PE 临床可能性较高并伴有休克或低血压 [即，收缩压<90 mmHg]），无抗凝或溶栓禁忌证
高风险或中高度风险，存在抗凝治疗或溶栓的禁忌证
PESI/sPESI 评分为中高度风险，无抗凝治疗或溶栓禁忌证
PESI/sPESI 评分为中低风险或低风险，无抗凝治疗的禁忌证
PESI/sPESI 评分为中低风险或低风险，存在抗凝治疗的禁忌证
确诊 PE：无潜在恶性肿瘤、非妊娠、无抗凝治疗禁忌证
确诊 PE：恶性肿瘤，无抗凝治疗禁忌证
确诊 PE：妊娠，无抗凝治疗禁忌证
确诊 PE：重度肾功能损伤，无抗凝治疗禁忌证
确诊 PE：肝功能损伤和凝血障碍，无抗凝治疗禁忌证
确诊 PE：PE 复发
撰稿人
作者
Scott M. Stevens, MD
Director
Thrombosis Clinic
Intermountain Medical Center
Murray
UT
Professor of Medicine
Department of Internal Medicine
University of Utah
Salt Lake City
UT
利益声明
SMS is an investigator for two investigator-initiated clinical trials for which his institution receives funds from Bristol-Myers Squibb to enrol patients.
Scott C. Woller, MD
Director
Thrombosis Clinic
Intermountain Medical Center
Murray
UT
Professor of Medicine
University of Utah
Salt Lake City
UT
利益声明
SCW holds two investigator-initiated grants from Bristol-Myers Squibb/Pfizer paid to his employer Intermountain Healthcare for which he receives no compensation. He has been invited to serve as co-chair of the American College of Chest Physicians guideline on antithrombotic therapy for venous thromboembolic disease (AT11) and serves as an invited panelist for the US Centers for Disease Control and Prevention venous thromboembolism risk assessment model systematic review and guidance panel.
Gabriel V. Fontaine, PharmD, BCPS
Clinical Coordinator
Critical Care Pharmacy
Advanced Clinical Pharmacist
Neuroscience Critical Care
Intermountain Medical Center
Murray
UT
利益声明
GVF receives consulting fees and honoraria from Portola Pharmaceuticals for clinical consulting and speaking engagements.
鸣谢
Scott M. Stevens, Scott C. Woller, and Gabriel V. Fontaine would like to gratefully acknowledge Geno Merli, Luis H. Eraso, Taki Galanis, Geoffrey Ouma, Miguel Angel de Gregorio, Alicia Laborda, and Seth W. Clemens, previous contributors to this topic.
利益声明
GM has received grants or research support from BMS, J&J, Sanofi-Aventis, Portola, and Janssen; he has served as a Scientific Consultant for BMS, J&J, and Sanofi-Aventis. LHE, TG, GO, MAG, AL, and SWC declare that they have no competing interests.
同行评议者
Keith Wille, MD, MSPH
Associate Professor of Medicine
University of Alabama at Birmingham
Birmingham
AL
利益声明
KW declares that he has no competing interests.
John R. Charpie, MD, PhD
Associate Professor of Pediatrics
Medical Director
Pediatric Cardiothoracic Intensive Care Unit
University of Michigan Congenital Heart Center
C.S. Mott Children's Hospital
Ann Arbor
MI
利益声明
JRC declares that he has no competing interests.
Sanjeev Wasson, MD
Advanced Clinical Fellow
Cleveland Clinic Foundation
Cleveland
OH
利益声明
SW declares that he has no competing interests.
David Jimenez, MD, PhD
Respiratory Physician and Associate Professor
Ramón y Cajal Hospital and Alcalá de Henares University
Respiratory Department and Medicine Department
Madrid
Spain
利益声明
DJ has received consulting fees from Boehringer Ingelheim, Bayer, Leo-Pharm, and Rovi, and lecture fees from Sanofi Aventis.
鉴别诊断
- 不稳定型心绞痛
- 非 ST 段抬高型心肌梗死 (NSTEMI)
- ST 段抬高型心肌梗死 (STEMI)
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