朱德才,秦锤雷,荣令,董慧芳,杜宣莉,马同亮,张传峰,李根
ZHU Decai,QIN Chuilei,RONG Ling,DONG Huifang,DU Xuanli,MA Tongliang,ZHANG Chuanfeng,LI Gen

• 1:亳州市人民医院急诊内科
• 2:亳州市人民医院呼吸科

摘要(Abstract)：

目的:探讨依诺肝素联合华法林对中低危急性肺栓塞(APE)的治疗效果,并分析影响治疗后患者预后的危险因素。方法:98例中低危APE患者均给予依诺肝素联合华法林治疗,观察治疗3个月时的疗效;于治疗前及治疗3个月时,采用全自动血气分析仪记录动脉血氧分压(PaO_2)、动脉二氧化碳分压(Pa CO_2)、氧合指数(OI)水平,采用超声心动图记录心率、室间隔厚度(IVST)、左房内径(LAD)、主动脉内径(AOD)及左室射血分数(LVEF)的变化;根据随访12个月时预后将患者分成预后良好组及预后不良组,比较2组患者性别、年龄、发绀、胸痛、呼吸困难、下肢肿痛、合并症、右心室功能不全、恶性肿瘤、出现APE症状至诊断时间等指标,采用Logistic回归模型分析影响患者预后不良的危险因素。结果:98例患者中,治愈27例(27.55%),显效38例(38.78%),有效21例(21.43%),无效12例(12.24%),总有效率为87.76%;患者治疗后Pa O_2、OI明显高于治疗前,Pa CO_2明显低于治疗前(P <0.01);治疗后IVST、LAD、AOD低于治疗前,LVEF高于治疗前(P <0.05);随访12月时,82例(83.67%)患者预后良好、16例(16.33%)预后不良;预后不良组患者合并症、右心室功能不全、恶性肿瘤、出现APE症状至诊断时间≥48 h占比高于预后良好组(P <0.05); Logistic回归分析显示,中低危APE患者的合并症、右心室功能不全、恶性肿瘤、出现症状至诊断时间≥48 h是预后不良的危险因素(P <0.05)。结论:依诺肝素联合华法林对中低危APE的疗效较好,患者的合并症、右心室功能不全、恶性肿瘤、出现症状至诊断时间延长是影响治疗效果的危险因素。
Objective: To explore the effect of enoxaparin combined with warfarin on the prognosis of patients with moderate and low-risk acute pulmonary embolism( APE),and analyze the risk factors of poor prognosis. Methods: Ninety-eight patients with moderate and low-risk APE were included. All patients were treated with enoxaparin and warfarin for 3 months. Before the treatment and at 3 months after the treatment,we detected the levels of arterial blood oxygen partial pressure(PaO_2),arterial carbon dioxide partial pressure( PaCO_2) and oxygenation index( OI) using blood gas analyzer,measured heart rate,ventricular septal thickness( IVST),left atrial diameter( LAD),aortic diameter( AOD) and left ventricular ejection fraction( LVEF) using echocardiography. After 12 month followup,all patients were divided into good-and bad prognosis groups according to their prognosis status.The clinical characteristics of the two groups were compared. The risk factors of poor prognosis were analyzed by Logistic regression model. Results: Among the 98 patients,27 patients( 27. 55%) were cured,38 patients( 38. 78%) were obviously effective,21 patients( 21. 43%) were effective and 12 patients( 12. 24%) were ineffective. The total effective rate was 87. 76%. The treatment significantly increased PaO_2 and OI,but decreased PaCO_2( P < 0. 05). Moreover,the treatment greatly decreased IVST,LAD and AOD,but upregulated LVEF( P < 0. 05). For the prognosis,82 patients( 83. 67%)had a good prognosis,16 patients( 16. 33%) had a bad prognosis. The proportions of right ventricular dysfunction,malignant tumor,symptom to diagnosis time ≥ 48 h were significantly higher in the patients with poor prognosis than the patients with good prognosis( P < 0. 05). Logistic regression analysis showed that the complications,right ventricular dysfunction,malignant tumors and the time from symptoms to diagnosis≥48 h were the risk factors of poor prognosis( P < 0. 05). Conclusion:The efficacy of enoxaparin combined with warfarin for APE is ideal,but the complications,right ventricular dysfunction,malignant tumors as well as symptoms and delayed diagnosis time are risk factors for poor prognosis.

关键词(KeyWords)： 华法林;依诺肝素;血气分析;危险因素;急性肺栓塞;预后不良
warfarin;enoxaparin;blood gas analysis;risk factors;acute pulmonary embolis(APE) m;poor prognosis

Abstract:

Keywords:

基金项目(Foundation): 国家自然科学基金资助项目(81571528)

作者(Author): 朱德才,秦锤雷,荣令,董慧芳,杜宣莉,马同亮,张传峰,李根
ZHU Decai,QIN Chuilei,RONG Ling,DONG Huifang,DU Xuanli,MA Tongliang,ZHANG Chuanfeng,LI Gen

DOI: 10.19367/j.cnki.2096-8388.2020.08.012

参考文献(References)：

• [1]STEIN P D,MATTA F,HUGHES M J.Inferior vena cava filters in stable patients with acute pulmonary embolism who receive thrombolytic therapy[J].The American Journal of Medicine,2017,131(1):97-99．
• [2]KONG T,PARK Y S,LEE H S,et al.Value of the delta neutrophil index for predicting 28-day mortality in patients with acute pulmonary embolism in the emergency department[J].Shock,2018,49(6):649-756．
• [3]米玉红，陆艳辉，王海云，等．中危急性肺栓塞患者补救性溶栓治疗时机初探及理念更新[J]．中华急诊医学杂志，2019,28(8):921-926．
• [4]胡梦玮，张思泉．中药联合华法林治疗急性次大面积肺栓塞的临床疗效[J]．中华中医药学刊，2019,37(8):2029-2032．
• [5]王蔚，王耀丽，周健，等．重症监护室术后并发急性肺栓塞患者的诊疗研究[J]．重庆医学，2018,47(1):29-31,34．
• [6]覃少佳，邓碧玉，张鸿魁，等．中危肺栓塞诊断和治疗的研究进展[J]．中外医学研究，2019,17 (3):186-188．
• [7]中华医学会心血管病学分会肺血管病学组．急性肺栓塞诊断与治疗中国专家共识(2015)[J]．中华心血管病杂志，2016,44(3):197-211．
• [8]JIMENEZ D,DE MIGUEL-DEZ J,GUIJARRO R,et al.Trends in the management and outcomes of acute pulmonary embolism:analysis from the riete registry[J].Journal of the American College of Cardiology,2016,67(2):162-170．
• [9]ALEVA F E,VOETS L W L M,SIMONS S O,et al.Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of copd:a systematic review and meta-analysis[J].Chest,2016,151 (3):544-554．
• [10]蒋雷，陈旭锋，黄培培．溶栓和抗凝治疗中高危肺栓塞的疗效[J]．江苏医药，2017,43(24):1816-1818．
• [11]魏广强，孙柏林．低分子肝素治疗癌症相关性急性肺血栓栓塞症的临床观察[J]．中国药房，2015,26(24):3349-3351．
• [12]李亚华，陈刚．甲强龙、低分子肝素对肺脂肪栓塞致急性呼吸窘迫综合征的防治作用的研究[J]．中华急诊医学杂志，2016,25(3):310-313．
• [13]陈润芝，周文华，宋巧凤，等．抗凝治疗急性非大面积肺栓塞疗效观察[J]．现代中西医结合杂志，2015,24(7):729-731．
• [14]李金玉，程爱斌，施举红．华法林对凝血因子及出凝血时间的影响[J]．中华医学杂志，2017,97(42):3347-3349．
• [15]李玄庶，张学民，贾哲，等．急性肺栓塞的介入治疗[J]．中华普通外科杂志，2017,32(2):129-132．
• [16]HARIHARAN P,DUDZINSKI D M,ROSOVSKY R,et al.Relation between clot burden,right sided heart strain and adverse events after acute pulmonary embolism[J].The American Journal of Cardiology,2016,118 (10):1568-1573．
• [17]洪城，高艺洋，张萌，等．肺腺癌合并肺栓塞患者临床特征分析[J]．国际呼吸杂志，2017,37(18):1379-1383．
• [18]张必磊，黄中伟．白细胞计数在急性肺栓塞患者入院早期危险分层中的作用[J]．中国急救复苏与灾害医学杂志，2015,10(11):1069-1071．
• [19]杜贤荣，李彩霞，郭星星．急诊科急性肺栓塞患者的临床特点分析[J]．中国药物与临床，2019,19(11):1877-1879．
• [20]罗培，刘冬梅，房建斌，等．低分子肝素联合华法林及丹参多酚酸盐治疗中、低危急性肺栓塞患者的疗效[J]．贵州医科大学学报，2017,42(1):97-100,104.

文章评论(Comment)：