Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN.
Acad Emerg Med. 2018 Jul;25(7):828-835. doi: 10.1111/acem.13399. Epub 2018 May 8.
This systematic review addresses the controversy over the decision to anticoagulate patients with subsegmental pulmonary embolism (SSPE).
We searched Ovid MEDLINE, PubMed, Embase, the Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, Google Scholar, and bibliographies in March 2017. Two authors reviewed and retained papers with symptomatic patients who underwent computerized tomographic pulmonary angiography and had sufficient information to determine SSPE; decision to treat (or not) with systemic anticoagulation; and outcomes of bleeding, venous thromboembolism (VTE) recurrence, and death. Papers were assessed for selection and publication bias and heterogeneity, with Eggers and the inconsistency indexes (I ).
From 1,512 papers screened, we included 14 studies comprising 15,563 patients for full-length review and analysis. Pooled data demonstrated I = 99% with an Eggers p < 0.001, suggesting significant publication bias. The pooled prevalence of SSPE was 4.6% (95% confidence interval [CI] = 1.8%-8.5%). The frequency of bleeding in SSPE patients treated with anticoagulation (n = 589) was 8.1% (95% CI = 2.8%-15.8%), with no available bleeding data in untreated patients (n = 126). The frequency of VTE recurrence within 90 days was 5.3% (95% CI = 1.6%-10.9%) for treated versus 3.9% (95% CI = 4.8%-13.4%) for untreated, while the frequency of death was 2.1% (95% CI = 3.4%-5.2%) for treated versus 3.0% (95% CI = 2.8%-8.6%) for untreated.
This systematic review highlights the lack of any clinical trial to make a clear inference about harm or benefit of anticoagulation for SSPE. Comparison of pooled data from uncontrolled outcome studies shows no increase in VTE recurrence or death rates for patients who were not anticoagulated. These data suggest clinical equipoise for decision to anticoagulate or not anticoagulate patients with SSPE. However, this inference is limited by small numbers, imprecision, and the lack of a controlled clinical trial.
本系统评价旨在解决亚段肺栓塞（SSPE）患者抗凝治疗决策的争议。
我们于 2017 年 3 月检索了 Ovid MEDLINE、PubMed、Embase、Cochrane 图书馆、Scopus、Web of Science、ClinicalTrials.gov、Google Scholar 和参考文献。两位作者对纳入的研究进行了评价，并保留了经计算机断层肺动脉造影（CTPA）检查且有足够信息确定为 SSPE 的有症状患者的研究；是否接受全身性抗凝治疗的决策；以及出血、静脉血栓栓塞（VTE）复发和死亡的结局。评估了这些研究的选择偏倚、发表偏倚和异质性，采用 Eggers 和不一致指数（I ）。
在筛选出的 1512 篇论文中，我们纳入了 14 项研究，共纳入 15563 例患者进行了全面评价和分析。汇总数据显示 I = 99%，Eggers p < 0.001，提示存在显著的发表偏倚。SSPE 患者的汇总发生率为 4.6%（95%可信区间 [CI]：1.8%-8.5%）。接受抗凝治疗的 SSPE 患者出血发生率为 8.1%（95% CI：2.8%-15.8%），未接受抗凝治疗的 SSPE 患者出血发生率无可用数据（n = 126）。治疗组 90 天内 VTE 复发的频率为 5.3%（95% CI：1.6%-10.9%），未治疗组为 3.9%（95% CI：4.8%-13.4%），治疗组死亡率为 2.1%（95% CI：3.4%-5.2%），未治疗组为 3.0%（95% CI：2.8%-8.6%）。
本系统评价强调缺乏任何临床试验来明确推断抗凝治疗对 SSPE 的危害或益处。对非对照结局研究的汇总数据进行比较显示，未抗凝治疗患者的 VTE 复发或死亡率并未增加。这些数据表明，在决定是否对 SSPE 患者进行抗凝治疗时，临床情况势均力敌。但是，由于病例数量少、不精确和缺乏对照临床试验，这种推断受到限制。
