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1、ThrombolyticsforAcutePulmonaryEmbolismfromthe ACCPGuidelines,9thEd.TheACCP’srecommendationclassificationsystem:·1=“recommendation”·2=“suggestion”·A=basedonstrongevidencefromrandomizedtrials·B=moderateevidencethatmayincluderandomizedtrialsorobservationalstudies·C=weakevi
2、dence,mostlyconsensusopinionWhichpatientswithacutepulmonaryembolismshouldItreatwithsystemicthrombolytics?·TheACCPsuggestsusingsystemicthrombolyticstotreatpatientswithacutePEwhoarehypotensive(theyproposeacutoffofsystolicbloodpressurelessthan90mmHg).(Grade2C).·ACCPrecomme
3、nds against treatingmostpatientswithacutePEwithouthypotensionwithsystemicthrombolytics(Grade1C).·However,patientsdeemedtobeat highrisk forbecominghypotensiveaccordingtoclinicalcoursearesuggestedtoreceivesystemicthrombolytics,iftheyhavealowbleedingrisk(Grade2C).“Lookings
4、ick,”dyspneicandhypoxic,rightventriculardysfunctiononechocardiogram,elevatedtroponins,elevatedneckveins,severetachycardiahaveallbeenproposedasriskfactors.HowshouldItreatacutepulmonaryembolismwithsystemicthrombolytics?·Ashortinfusiontimeof2hoursforsystemicthrombolyticsis
5、suggested,ratherthanalongerinfusion(Grade2C). Tissueplasminogenactivator(tPA)hasashortinfusiontimeandhasbeenrecommendedasthebestagentforthisreason.·Infusesystemicthrombolyticsthroughaperipheralvein,ratherthanapulmonaryarterycatheter(Grade2C).Randomizedtrialsshowthatthro
6、mbolyticsimprovepulmonaryarterypressures,oxygenation,andcardiacperformanceonechocardiographywithin24hoursinpeoplewithacutepulmomaryembolism.However,thiscomesatasignificantlyhigherriskofbleedingcomparedtoothertherapies.13randomizedtrialsandtheirmeta-analysessuggestthatth
7、rombolytictherapymayreducemortalityandrecurrentpulmonaryembolus,butreviewersshareahighsuspicionforpublicationbiasandunevenqualitybetweenstudies.Inotherwords,thrombolytics’benefitsinreducingmortalityfromacutePEremainunknown.Further,riskstratificationmodelshavenotbeenvali
8、datedprospectively(neitherthosepredictingdeathfromPEnorthosepredictingbleedingfromthrombolytictherapy),sorisk/
