Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia.
UO Cardiologia, Ospedale San Carlo Borromeo, Milano.
Chest. 2013 Nov;144(5):1539-1545. doi: 10.1378/chest.12-2938.
In hemodynamically stable patients with acute pulmonary embolism, risk stratification is essential to drive clinical management. In these patients, risk stratification for in-hospital adverse outcomes based on markers of right ventricular dysfunction and injury has been proposed.
The aim of this study was to validate a model based on the incremental prognostic value of right ventricular dysfunction and injury in hemodynamically stable patients with acute pulmonary embolism. Patients from the prospective Italian Pulmonary Embolism Registry were included in the study. Study outcomes were in-hospital death and the composite of in-hospital death or clinical deterioration.
Among 1,515 hemodynamically stable patients, 869 had both echocardiography and troponin assessments. The risk for in-hospital death or clinical deterioration was higher in patients with right ventricular dysfunction and elevated troponin level (8.8%; hazard ratio [HR], 14.2 [95% CI, 1.94-104.16]; P < .01) and with either right ventricular dysfunction or elevated troponin level (4.7%; HR, 7.9 [95% CI, 1.1-59.9]; P < .05) compared with patients without dysfunction and normal troponin levels. The negative predictive value of the model was 100% for in-hospital death and 99% for death or clinical deterioration. C statistics showed an improvement of the discriminatory power for in-hospital death or clinical deterioration by using the overall model (0.66; 95% CI, 0.60-0.73) over either echocardiography (0.59; 95% CI, 0.53-0.67) or troponin level (0.61; 95% CI, 0.53-0.69) alone.
A model that includes both dysfunction and injury of the right ventricle has an incremental prognostic value for risk stratification in hemodynamically stable patients with acute pulmonary embolism. Patients with no dysfunction or injury have a favorable outcome.
ClinicalTrials.gov; No.: NCT01604538; URL: www.clinicaltrials.gov.
在血流动力学稳定的急性肺栓塞患者中，风险分层对于指导临床管理至关重要。在这些患者中，已经提出了基于右心室功能障碍和损伤标志物的住院期间不良结局的风险分层。
本研究旨在验证一种基于血流动力学稳定的急性肺栓塞患者右心室功能障碍和损伤的增量预后价值的模型。前瞻性意大利肺栓塞注册研究纳入了该研究。研究结局为住院期间死亡和住院期间死亡或临床恶化的复合结局。
在 1515 例血流动力学稳定的患者中，869 例同时进行了超声心动图和肌钙蛋白评估。伴有右心室功能障碍和肌钙蛋白水平升高的患者（8.8%；危险比[HR]，14.2[95%CI，1.94-104.16]；P <.01）和伴有右心室功能障碍或肌钙蛋白水平升高的患者（4.7%；HR，7.9[95%CI，1.1-59.9]；P <.05）的住院期间死亡或临床恶化风险高于无功能障碍和正常肌钙蛋白水平的患者。该模型对住院期间死亡和死亡或临床恶化的阴性预测值分别为 100%和 99%。C 统计数据表明，与单独使用超声心动图（0.59；95%CI，0.53-0.67）或肌钙蛋白水平（0.61；95%CI，0.53-0.69）相比，使用整体模型（0.66；95%CI，0.60-0.73）可提高住院期间死亡或临床恶化的鉴别能力。
一种包含右心室功能障碍和损伤的模型对血流动力学稳定的急性肺栓塞患者的风险分层具有增量预后价值。无功能障碍或损伤的患者具有良好的预后。
ClinicalTrials.gov；编号：NCT01604538；网址：www.clinicaltrials.gov。
