Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA.
Jaron D. RaperDepartment of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Acad Emerg Med. 2022 Jul;29(7):835-850. doi: 10.1111/acem.14484. Epub 2022 Apr 23.
Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the Simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to (1) determine if RV assessment variables add prognostic accuracy for 5-day clinical deterioration in patients classified low risk by sPESI, and (2) determine the prognostic importance of RV assessments compared to other variables and to each other.
We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed, and compared prognostic accuracy of, full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE.
Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by CT, 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77-0.82) and 0.71 (0.68-0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5-day clinical deterioration by the multivariable logistic regression.
A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5-day clinical deterioration versus one without.
识别右心室（RV）异常对于分层肺栓塞（PE）的严重程度很重要。处置决策受到对早期恶化的担忧的影响。分诊策略，如简化肺栓塞严重指数（sPESI），并未将 RV 评估作为预测因素或早期恶化作为结局。我们的目的是：（1）确定 RV 评估变量是否为 sPESI 分类低危患者 5 天临床恶化的预后准确性，以及（2）确定 RV 评估与其他变量和彼此相比的预后重要性。
我们从前瞻性 PE 登记处确定了 sPESI 低危患者（sPESI=0）。从大量候选变量中，我们开发了全和简化随机森林模型（分别具有和不具有 RV 评估变量），并在验证数据库上比较了其预后准确性。我们报告了全随机森林的变量重要性图，并提供了多变量逻辑回归的重要性统计推断的优势比。结局为 PE 后 5 天内死亡、心脏骤停、低血压、心律失常或呼吸衰竭。
在 1736 例患者中，610 例（35.1%）根据 sPESI 为低危，72 例（11.8%）发生早期恶化。在这 610 例患者中，CT 显示 RV 异常 157 例（25.7%），超声心动图显示 121 例（19.8%），利钠肽显示 132 例（21.6%），肌钙蛋白显示 107 例（17.5%）。对于恶化，全和简化随机森林预后模型的接收者操作特征分别为 0.80（0.77-0.82）和 0.71（0.68-0.73）。RV 评估在随机森林模型的变量重要性图中排名前四。超声心动图和 CT 通过多变量逻辑回归显著增加了 5 天临床恶化的预测概率。
与不使用 RV 成像评估的策略相比，具有 RV 成像评估的 PE 分诊策略在分类低危患者 5 天临床恶化方面具有更好的预后性能。
