作者：李晓花1 ，张东光 1 ，李为 2

单位：

1.234000 安徽省宿州市，皖北煤电集团总医院呼吸与危重症医学科；2.234000 安徽省宿州市，皖北煤电集团总医院心血管内科；通信作者：李晓花，E-mail：Zg90958@163.com

Units：

1.Department of Respiratory and Critical Care Medicine，General Hospital of Wanbei Coal and Power Group，Suzhou234000，China；2.Department of Cardiology，General Hospital of Wanbei Coal and Power Group，Suzhou 234000，China；Corresponding author：LI Xiaohua，E-mail：Zg90958@163.com

关键词：

肺栓塞；静脉血栓形成；危险分层；右心功能

Keywords：

Pulmonary embolism；Venous thrombosis；Risk stratification；Right heart function

CLC：

R 563.5　R 543

DOI：

DOI：10.3969/j.issn.1008-5971.2020.01.y08

Funds：

摘要：

背景　肺动脉栓子主要来源于下肢深静脉血栓，而栓子阻塞肺动脉及其分支可导致肺血管阻力增加及右心功能改变，但目前下肢深静脉栓塞及右心功能改变对急性肺栓塞（APE）患者的影响尚未完全明确。目的　探讨APE 患者下肢深静脉栓塞情况和右心功能改变及其临床意义。方法　选取 2016—2018 年皖北煤电集团总医院收治的疑似 APE 患者 80 例，根据 CT 肺动脉造影（CTPA）检查结果分为 APE 组 32 例和非 APE 组 48 例，并根据 APE 危险分层标准将 32 例 APE 患者分为低危组 8 例、中危组 18 例和高危组 6 例。比较 APE 组与非 APE 组患者临床症状及体征、基础疾病、实验室检查指标、下肢深静脉栓塞情况、右心功能指标，并比较低危组、中危组、高危组患者下肢深静脉栓塞情况、右心功能指标。结果　（1）APE 组与非 APE 组患者咯血、胸痛、胸闷、心悸、意识障碍、咳嗽、发热、低血压、慢性阻塞性肺疾病（COPD）、高血压、冠心病、心房颤动、肿瘤发生率比较，差异无统计学意义（P>0.05）；APE组患者晕厥、单侧下肢肿胀、血脂异常发生率，有近期手术史或骨折者所占比例，红细胞计数及尿酸、纤维蛋白原、D-二聚体水平高于非 APE 组（P<0.05）。（2）APE 组患者栓塞血管数目多于非 APE 组，栓子直径、右心室舒张末期内径（RVEDD）/ 左心室舒张末期内径（LVEDD）大于非 APE 组，双侧深静脉栓塞、深静脉栓塞、近端深静脉栓塞发生率高于非 APE 组，右心室壁运动幅度（RVWM）、右房室瓣环收缩期位移（TAPSE）小于非 APE 组，右房室瓣反流速度（TRV）快于非 APE 组（P<0.05）。（3）高危组患者栓塞血管数目多于低危组、中危组，栓子直径、RVEDD/LVEDD 大于低危组、中危组，双侧深静脉栓塞、近端深静脉栓塞发生率高于低危组、中危组，RVWM、TAPSE 小于低危组、中危组，TRV 快于低危组、中危组（P<0.05）；中危组患者栓塞血管数目多于低危组，栓子直径、RVEDD/LVEDD 大于低危组，双侧深静脉栓塞、近端深静脉栓塞发生率高于低危组，RVWM、TAPSE 小于低危组，TRV 快于低危组（P<0.05）。低危组、中危组、高危组患者深静脉栓塞发生率比较，差异无统计学意义（P>0.05）。结论APE 患者多存在下肢深静脉栓塞及右心功能改变，且 APE 危险分层越高，下肢深静脉栓塞越严重、右心功能改变越大，因此针对出现下肢深静脉栓塞及右心功能改变的疑似 APE 患者需及时行 CTPA 检查以明确诊断并进行危险分层，以提高 APE 的防治效果。

Abstract：

Backgroud　Pulmonary artery embolus mainly derive from lower extremity deep venous thrombosis，while embolus blocking in pulmonary artery and its branches may lead to increase of pulmonary vascular resistance and changeof right ventricular function，but the impact of venous embolism of lower extremity and change of right ventricular function onpatients with acute pulmonary embolism（APE）is not very clear yet. Objective　To investigate the deep venous embolism oflower extremity and change of right ventricular function in patients with APE and its clinical significance . Methods　A totalof 80 patients with suspected APE were selected in General Hospital of Wanbei Coal and Power Group from 2016 to 2018，and they were divided into APE group（n=32）and non-APE group（n=48）according to the CTPA examination results，andthen the 32 patients with APE were divided into A group（with low-risk APE，n=8），B group（with medium-risk APE，n=18）and C group（with high-risk APE，n=6）according to APE risk stratification criteria. Clinical symptoms and signs，basic diseases，laboratory examination results，deep venous embolism of lower extremity and index of right ventricular functionwere compared between APE group and non-APE group，meanwhile deep venous embolism of lower extremity and index of rightventricular function were compared in groups A，B and C. Results　（1）No statistically significant difference of incidenceof hemoptysis，chest pain，chest distress，palpitation，consciousness disorder，cough，fever，hypotension，COPD，hypertension，coronary heart disease，atrial fibrillation or tumour was found between APE group and non-APE group（P>0.05）；incidence of syncope，unilateral lower limb swelling and dyslipidemia，proportion of patients with recent surgical history orfracture，RBC，UA，FIB and D-dimer in APE group were statistically significantly higher than those in non-APE group（P<0.05）.（2）Number of embolized vessels in APE group was statistically significantly more than that in non-APE group，diameter of embolus and RVEDD/LVEDD ratio in APE group were statistically significantly greater than those in non-APEgroup，incidence of bilateral deep venous embolization，deep venous thrombosis and proximal deep venous embolization in APEgroup were statistically significantly higher than those in non-APE group，RVWM and TAPSE in APE group were statisticallysignificantly smaller than those in non-APE group，moreover TRV in APE group was statistically significantly faster than thatin non-APE group（P<0.05）.（3）Number of embolized vessels in C group was statistically significantly more than that in Agroup and B group，respectively，diameter of embolus and RVEDD/LVEDD ratio in C group was statistically significantly greaterthan that in A group and B group，respectively，incidence of bilateral deep venous embolization and proximal deep venousembolization in C group was statistically significantly higher than that in A group and B group，respectively，RVWM and TAPSEin C group was statistically significantly smaller than that in A group and B group，respectively，moreover TRV in C group wasstatistically significantly faster than that in A group and B group，respectively（P<0.05）；number of embolized vessels in Bgroup was statistically significantly more than that in A group，diameter of embolus and RVEDD/LVEDD ratio in B group werestatistically significantly greater than those in A group，incidence of bilateral deep venous embolization and proximal deep venousembolization in B group was statistically significantly higher than that in A group，respectively，RVWM and TAPSE in B groupwere statistically significantly smaller than those in A group，moreover TRV in B group was statistically significantly faster thanthat in A group（P<0.05）.No statistically significant difference of incidence of deep venous embolization was found in groups A，B and C（P>0.05）. Conclusion　There are deep venous embolism of lower extremity and change of right ventricular functionin patients with APE，and as risk stratification increase，severity of deep venous embolism of lower extremity aggravates andchange of right ventricular function increase，thus it is necessary to carry out CTPA when we found suspected APE patients withdeep venous embolism of lower extremity and change of right ventricular function on clinic，to make a definite diagnosis and clearrisk stratification，eventually improve the prevention and control ability for APE.

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