Kohn Christine G, Mearns Elizabeth S, Parker Matthew W, Hernandez Adrian V, Coleman Craig I
University of Saint Joseph School of Pharmacy, Hartford, CT.
University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT; University of Connecticut School of Pharmacy, Storrs, CT.
Chest. 2015 Apr;147(4):1043-1062. doi: 10.1378/chest.14-1888.
Studies suggest outpatient treatment or early discharge of patients with acute pulmonary embolism (aPE) is reasonable for those deemed to be at low risk of early mortality. We sought to determine clinical prediction rule accuracy for identifying patients with aPE at low risk for mortality.
We performed a literature search of Medline and Embase from January 2000 to March 2014, along with a manual search of references. We included studies deriving/validating a clinical prediction rule for early post-aPE all-cause mortality and providing mortality data over at least the index aPE hospitalization but ≤ 90 days. A bivariate model was used to pool sensitivity and specificity estimates using a random-effects approach. Traditional random-effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low risk for early mortality and their ORs for death compared with high-risk patients.
Forty studies (52 cohort-clinical prediction rule analyses) reporting on 11 clinical prediction rules were included. The highest sensitivities were observed with the Global Registry of Acute Coronary Events (0.99, 95% CI = 0.89-1.00), Aujesky 2006 (0.97, 95% CI = 0.95-0.99), simplified Pulmonary Embolism Severity Index (0.92, 95% CI = 0.89-0.94), Pulmonary Embolism Severity Index (0.89, 95% CI = 0.87-0.90), and European Society of Cardiology (0.88, 95% CI = 0.77-0.94) tools, with remaining clinical prediction rule sensitivities ranging from 0.41 to 0.82. Of these five clinical prediction rules with the highest sensitivities, none had a specificity > 0.48. They suggested anywhere from 22% to 45% of patients with aPE were at low risk and that low-risk patients had a 77% to 97% lower odds of death compared with those at high risk.
Numerous clinical prediction rules for prognosticating early mortality in patients with aPE are available, but not all demonstrate the high sensitivity needed to reassure clinicians.
研究表明，对于那些被认为早期死亡风险较低的急性肺栓塞（aPE）患者，门诊治疗或早期出院是合理的。我们试图确定用于识别aPE低死亡风险患者的临床预测规则的准确性。
我们对2000年1月至2014年3月的Medline和Embase进行了文献检索，并手动检索了参考文献。我们纳入了推导/验证aPE后早期全因死亡率临床预测规则并至少提供索引aPE住院期间但≤90天死亡率数据的研究。使用双变量模型通过随机效应方法汇总敏感性和特异性估计值。进行传统的随机效应荟萃分析，以估计被认为早期死亡风险低的患者的加权比例及其与高风险患者相比的死亡比值比。
纳入了40项研究（52项队列 - 临床预测规则分析），报告了11种临床预测规则。全球急性冠状动脉事件注册研究（0.99，95%CI = 0.89 - 1.00）、奥耶斯基2006年研究（0.97，95%CI = 0.95 - 0.99）、简化肺栓塞严重程度指数（0.92，95%CI = 0.89 - 0.94）、肺栓塞严重程度指数（0.89，95%CI = 0.87 - 0.90）和欧洲心脏病学会（0.88，95%CI = 0.77 - 0.94）工具观察到最高敏感性，其余临床预测规则的敏感性范围为0.41至0.82。在这五个敏感性最高的临床预测规则中，没有一个特异性>0.48。它们表明aPE患者中有22%至45%处于低风险，与高风险患者相比，低风险患者的死亡几率低77%至97%。
有许多用于预测aPE患者早期死亡率的临床预测规则，但并非所有规则都具有让临床医生放心所需的高敏感性。
