Taylor R Andrew, Davis Jennifer, Liu Rachel, Gupta Vishal, Dziura James, Moore Christopher L
Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut 06510, USA.
J Emerg Med. 2013 Sep;45(3):392-9. doi: 10.1016/j.jemermed.2013.04.014. Epub 2013 Jul 2.
In patients with pulmonary embolism (PE), right ventricular strain (RVS) on transthoracic echocardiography by Cardiology has been shown to be an independent predictor of 30-day adverse outcomes. However, it is not known how emergency practitioner-performed point-of-care focused cardiac ultrasound (FOCUS) with assessment for RVS compares with other prognostic methods in the Emergency Department (ED).
To determine whether RVS on FOCUS is a significant predictor of in-hospital adverse outcomes when compared to other risk factors and scoring systems.
Retrospective chart review of patients who were diagnosed with PE and had a FOCUS examination during January 1, 2007 through January 1, 2011 in an urban, academic center with a well-developed ultrasound program. Adverse outcomes were defined as shock, respiratory failure requiring intubation, death, recurrent venous thromboembolism, transition to higher level of care, or major bleeding during hospital admission. Statistical analysis included univariate and multivariate analysis to assess for prognostic significance.
One hundred sixty-one patients were included in the final analysis. A total of 25 (16%) patients had an adverse outcome during hospitalization. On univariate analysis, only the presence of altered mental status conferred a higher positive likelihood ratio (6.4 vs. 4.0) than RVS, whereas absence of RVS had the lowest negative likelihood ratio (0.45). On multivariate analysis, RVS and cardiopulmonary disease were the only predictors of adverse outcomes that achieved statistical significance, with odds ratio of 9.2 and 3.4, respectively.
In this retrospective chart review, a FOCUS examination for RVS performed by emergency care practitioners of varying experience level was a significant predictor of in-hospital adverse outcomes among patients diagnosed with PE in the ED. Future research should be directed at exploring ways to incorporate RVS assessment into ED prognostic models for pulmonary embolism.
在肺栓塞（PE）患者中，经胸超声心动图显示的右心室应变（RVS）已被证明是30天不良结局的独立预测因素。然而，尚不清楚急诊科医生进行的以即时护理为重点的心脏超声检查（FOCUS）对RVS的评估与急诊科（ED）中的其他预后方法相比如何。
确定与其他风险因素和评分系统相比，FOCUS检查中的RVS是否是住院不良结局的重要预测因素。
对2007年1月1日至2011年1月1日期间在一个拥有完善超声项目的城市学术中心被诊断为PE并接受FOCUS检查的患者进行回顾性病历审查。不良结局定义为休克、需要插管的呼吸衰竭、死亡、复发性静脉血栓栓塞、转至更高护理级别或住院期间大出血。统计分析包括单因素和多因素分析以评估预后意义。
161名患者纳入最终分析。共有25名（16%）患者在住院期间出现不良结局。单因素分析中，只有精神状态改变的阳性似然比（6.4对4.0）高于RVS，而无RVS的阴性似然比最低（0.45）。多因素分析中，RVS和心肺疾病是仅有的达到统计学意义的不良结局预测因素，比值比分别为9.2和3.4。
在这项回顾性病历审查中，不同经验水平的急救医生进行的FOCUS检查对RVS的评估是急诊科诊断为PE的患者住院不良结局的重要预测因素。未来的研究应致力于探索将RVS评估纳入肺栓塞的ED预后模型的方法。
