Stamm Jason A, Long Joshua L, Kirchner H Lester, Keshava Keerthana, Wood Kenneth E
From the Department of Medicine, Geisinger Medical Center, Danville, Pennsylvania.
South Med J. 2014 Feb;107(2):72-8. doi: 10.1097/SMJ.0000000000000053.
Guidelines have recommended that risk stratification be performed in patients diagnosed with an acute pulmonary embolism (PE). No study has described the use of risk stratification in routine clinical practice. The purpose of this study was to measure the frequency and impact of risk stratification on treatment decisions and outcomes in patients admitted with acute PE.
A retrospective cohort study was conducted of all of the patients admitted with acute PE at two Geisinger community-based teaching hospitals between 2006 and 2011. Baseline demographics, vital signs, and relevant clinical variables were recorded. The Pulmonary Embolism Severity Index was calculated for each patient. Risk stratification was defined as the measurement of either a biomarker or an echocardiogram within 24 hours of admission. The outcomes measured were short-term adverse events (in-hospital mortality or need for intensive care) and 30-day mortality.
The mean age for the study cohort (n = 889) was 61 ± 17 years and 52% were men. Overall, 59% of study subjects were risk stratified. The frequency of risk stratification did not change over time. Risk stratification was associated with assignment to a higher acuity of care and increased use of thrombolysis and inferior vena cava filter placement. When controlling for severity of illness, risk stratification was a significant predictor of worsened short-term adverse outcome (odds ratio 3.43, 95% confidence interval 1.75-6.74, P < 0.001) but was not associated with improved 30-day mortality (odds ratio 1.14, 95% confidence interval 0.66-1.95, P = 0.64).
Risk stratification is frequently performed in patients admitted with acute PE and has had a stable prevalence during a 5-year period. The use of risk stratification in acute PE is associated with assignment to higher levels of care and with more advanced treatments. Despite more intense treatment, risk stratification does not improve either short-term outcomes or 30-day mortality.
指南推荐对诊断为急性肺栓塞（PE）的患者进行危险分层。尚无研究描述危险分层在常规临床实践中的应用情况。本研究的目的是测定急性PE患者中危险分层的频率及其对治疗决策和预后的影响。
对2006年至2011年间在两家基于社区的盖辛格教学医院收治的所有急性PE患者进行回顾性队列研究。记录基线人口统计学资料、生命体征和相关临床变量。计算每位患者的肺栓塞严重程度指数。危险分层定义为入院24小时内对生物标志物或超声心动图进行检测。所测定的结局为短期不良事件（住院死亡率或入住重症监护病房的需求）和30天死亡率。
研究队列（n = 889）的平均年龄为61±17岁，男性占52%。总体而言，59%的研究对象进行了危险分层。危险分层的频率未随时间变化。危险分层与分配至更高的护理级别以及增加溶栓和下腔静脉滤器置入的使用相关。在控制疾病严重程度后，危险分层是短期不良结局恶化的显著预测因素（比值比3.43，95%置信区间1.75 - 6.74，P < 0.001），但与30天死亡率改善无关（比值比1.14，95%置信区间0.66 - 1.95，P = 0.64）。
急性PE患者中经常进行危险分层，且在5年期间患病率稳定。急性PE中危险分层的应用与分配至更高护理级别及更先进治疗相关。尽管治疗更为强化，但危险分层并未改善短期结局或30天死亡率。
