Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland.
Thorax. 2014 Sep;69(9):835-42. doi: 10.1136/thoraxjnl-2013-204762. Epub 2014 May 20.
Several factors have been associated with mortality in the months after PE. Factors associated with short-term clinical deterioration or need for hospital-based intervention are less well known.
We prospectively enrolled consecutive emergency department patients with PE and recorded clinical, biomarker and radiographic data. We assessed hospitalised patients daily to identify clinical deterioration or need for hospital-based intervention for 5 days after PE. We captured postdischarge events via 5-day and 30-day interviews. We used univariate and multivariable models to assess associations with clinical deterioration, severe clinical deterioration and 30-day all-cause mortality. We also assessed the test characteristics of three published clinical decision rules.
We enrolled 298 patients with PE: mean age 59 (SD±17) years; 152 (51%) male and 268 (90%) white race. 101 (34%) patients clinically deteriorated or required a hospital-based intervention within 5 days, and 197 (66%) did not. 27 (9%) patients suffered severe clinical deterioration and 12 died within 30 days. Factors independently associated with clinical deterioration were hypotension (p=0.001), hypoxia (p<0.001), coronary disease (p=0.004), residual deep vein thrombosis (p=0.006) and right heart strain on echocardiogram (p<0.001). In contrast, factors associated with 30-day all-cause mortality were active malignancy (p<0.001) and congestive heart failure (p=0.009). The sensitivity of clinical decision rules was moderate (39-80%) for 5-day clinical deterioration but higher (67-100%) for 30-day mortality.
Most patients do not clinically deteriorate after PE diagnosis. Several factors are associated with short-term clinical deterioration, but these factors differ from those associated with 30-day mortality.
已有多种因素与肺栓塞（PE）后数月的死亡率相关。与短期临床恶化或需要医院干预相关的因素则知之甚少。
我们前瞻性地纳入了连续的急诊 PE 患者，并记录了临床、生物标志物和影像学数据。我们每天对住院患者进行评估，以确定 PE 后 5 天内的临床恶化或需要医院干预的情况。我们通过 5 天和 30 天的访谈来获取出院后的事件。我们使用单变量和多变量模型来评估与临床恶化、严重临床恶化和 30 天全因死亡率相关的因素。我们还评估了三种已发表的临床决策规则的测试特征。
我们纳入了 298 例 PE 患者：平均年龄 59（±17）岁；152 例（51%）为男性，268 例（90%）为白人。101 例（34%）患者在 5 天内临床恶化或需要医院干预，而 197 例（66%）则没有。27 例（9%）患者发生严重临床恶化，12 例在 30 天内死亡。与临床恶化独立相关的因素有低血压（p=0.001）、低氧血症（p<0.001）、冠心病（p=0.004）、残留的深静脉血栓形成（p=0.006）和超声心动图上的右心应变（p<0.001）。相比之下，与 30 天全因死亡率相关的因素是活动性恶性肿瘤（p<0.001）和充血性心力衰竭（p=0.009）。临床决策规则的敏感性在 5 天临床恶化时为中等（39%-80%），但在 30 天死亡率时则较高（67%-100%）。
大多数患者在诊断为 PE 后不会出现临床恶化。有多种因素与短期临床恶化相关，但这些因素与 30 天死亡率相关的因素不同。
