家庭醫業 1, 2 3 3 肺栓塞的危險因子 1998 3.3 2008 7.4 [1] 25%-30% [2] 2%-8% [3] 學 [4] Virchow's triad (hypercoagulability) (stasis) (endothelial injury) 1 衛生福利部臺中醫院內科 2 中台科技大學醫療暨健康產業管理系 3 衛生福利部臺中醫院家庭醫學科 : pulmonary embolism, D-dimer, computed tomography pulmonary angiography, anticoagulants, thrombolytic therapy ( ) [5] [6] [7] [8] [9] 肺栓塞的臨床症狀 肺栓塞的診斷 Wells Geneva [10] ( ) [11] 140 家庭醫學與基層醫療 第五期
表一肺栓塞的臨床風險評估 Wells score 臨床上深部靜脈栓塞症狀 (+ 3) 年齡 >65 (+ 1) Geneva score 肺栓塞的診斷 (+ 3) 有深部靜脈栓塞或肺栓塞診斷史 (+ 3) 心跳 > 100 (+ 1.5) 4 週前開刀或下肢骨折 (+ 2) 至少 3 天沒有移動肢體或 4 週前開刀 (+ 1.5) 1 內有腫瘤診斷或治療 (+ 2) 有深部靜脈栓塞或肺栓塞診斷史 (+ 1.5) 單側下肢痛 (+ 3) 咳血 (+ 1) 咳血 (+ 2) 6 個月內有腫瘤診斷或治療 (+ 1) 心跳 < 75 (0) 75-94 (+ 3) 95 (+ 5) 下肢深部靜脈觸摸疼痛及單側水腫 (+ 4) 總分 0-1 低度可能性 2-6 中度可能性 6 高度可能性 資料來源 : 參考資料 10 總分 0-3 低度可能性 4-10 中度可能性 11 高度可能性 D-dimer [12] 肺栓塞的診斷工具 1. X (Fleishnersign) (Hampton hump) (Westermark's sign) 2. 3. D-dimer D-dimer 4. (Echocardiography) Nazeyrollas RV/LVEDD>0.5 tricuspid regurgitation flow peak velocity>2.5 m/ s 93% 81% [13] 5. (lung scan) (ventilation) (perfusion) 6. 家庭醫學與基層醫療 第五期 141
家 圖一 庭 醫 業 肺栓塞的建議診斷流程 資料來源 參考資料11 (multidetector computed tomography pulmonary angiography) 已逐漸取代 肺栓塞的治療 傳統式的肺動脈攝影 成為第一線診 高度風險的肺栓塞病人並有休克或 斷工具(圖二) 64切電腦斷層肺血管 低血壓時 可考量血栓溶解劑 如果病 攝影可提供87-91%的敏感度及特異性 人不適合血栓溶解劑 則考慮使用導管 的診斷 幫助血栓移除(catheter-assisted thrombus [14] removal)或開刀血栓切除術 此類病人也 需要鑑別診斷的急性病 是需要立即以未分段肝素(unfrationated heparin)抗凝血劑治療並給予呼吸系統及 1. 急性冠心症 血行動力學穩定的支持 對血行動力學穩 2. 主動脈剝離 定的非高度風險肺栓塞的病人 抗凝血劑 3. 心包膜填塞 是主要治療且要儘快給予治療 4. 肺炎 5. 氣胸 142 家 庭 醫 學 與 基 層 醫 療 傳統的抗凝血劑治療肺栓塞 第三十卷 第五期
圖二 多層次電腦斷層, 顯影劑後顯示右肺血管 filling defect ( 如箭頭 ) (anticoagulants) (unfractionated heparin, UFH) (low molecular weight heparin, LMWH heparin a a ) fondaparinux( pentasaccharide a) 5 7 K (vitamin K antagonists, VKAs) (PT) (international normalized ratio, INR)2.0 3.0 UFH 80 U/Kg 5,000 U 18 U/Kg/h 1,300 U/h aptt 1.5 2.5 VKAs INR 2.0 3.0 VKAs ( ) LMWH LMWH VKAs [15] (UHF) (LMWH) fondaparinux UHF 1 2 aptt 家庭醫學與基層醫療 第五期 143
aptt> 2.5 Protamine sulfate 3 4 UHF protamine sulfate1mg UHF 100 units LMWH LMWH a a protamine sulfate LMWH Fondaparinux Ccr<30 ml/min heparin induced thrombocytopenia ( ) [16,17] K (VKAs) VKAs warfarin 2 warfarin 36 72 2 3 7 K1 10 12 10 (thrombolytic therapy) ( ) 2 (urokinase, streptokinase r- TPA) (catheter-assisted thrombus removal) [15] IIa Xa rivaroxaban, dabigatran, apixaban edoxaban VKAs [11] 結論 D-dimer 參考資料 1. Chung WS, Lin CL, Hsu WH, Sung FC, Li RY, Kao CH: Idiopathic venous thromboembolism: a potential surrogate for occult cancer. QJM 144 家庭醫學與基層醫療 第五期
2014;107:529-36.. 2. Horlander KT, Mannino DM, Leeper KV: Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiplecause mortality data. Arch Intern Med 2003;163:1711-7. 3. Goldhaber SZ, Visani L, De Rosa M: Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353:1386-9. 4. Tapson VF: Acute pulmonary embolism. N Engl J Med 2008;358:1037-52. 5. Chung WS, Peng CL, Lin CL, et al: Rheumatoid arthritis increases the risk of deep vein thrombosis and pulmonary thromboembolism: a nationwide cohort study. Ann Rheum Dis 2014;73:1774-80. 6. Chung WS, Lin CL, Chang SN, Lu CC, Kao CH: Systemic lupus erythematosus increases the risks of deep vein thrombosis and pulmonary embolism: a nationwide cohort study. J Thromb Haemost 2014;12:452-8. 7. Chung WS, Lin CL, Sung FC, Hsu WH, Chen YF, Kao CH: Increased risks of deep vein thrombosis and pulmonary embolism in Sjogren syndrome: a nationwide cohort study. J Rheumatol 2014;41:909-15. 8. Chung WS, Lin CL, Sung FC, et al: Systemic sclerosis increases the risks of deep vein thrombosis and pulmonary thromboembolism: a nationwide cohort study. Rheumatology (Oxford) 2014;53:1639-45. 9. Chung WS, Lin CL, Sung FC, Lu CC, Kao CH: Increased Risk of Venous Thromboembolism in Patients with Dermatomyositis/Polymyositis: A Nationwide Cohort Study. Thromb Res 2014;134:622-6. 10. Chagnon I, Bounameaux H, Aujesky D, et al: Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med 2002;113:269-75. 11. Meyer G: Effective diagnosis and treatment of pulmonary embolism: Improving patient outcomes. Archives of cardiovascular diseases 2014;107:406-14. 12. Torbicki A, Perrier A, Konstantinides S, et al: Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29:2276-315. 13. Nazeyrollas P, Metz D, Jolly D, et al: Use of transthoracic Doppler echocardiography combined with clinical and electrocardiographic data to predict acute pulmonary embolism. Eur Heart J 1996;17:779-86. 14. Dewailly M, Remy-Jardin M, Duhamel A, et al: Computer-aided detection of acute pulmonary embolism with 64-slice multi-detector row computed tomography: impact of the scanning conditions and overall image quality in the detection of peripheral clots. J Comput Assist Tomogr 2010;34:23-30. 15. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ: Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133:454S-545S. 16. Douketis JD, Berger PB, Dunn AS, et al: The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133:299S-339S. 17. Warkentin TE, Greinacher A, Koster A, Lincoff AM: Treatment and prevention of heparininduced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133:340-80S. 家庭醫學與基層醫療 第五期 145