Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network.
Department of Emergency Medicine, University of California, Davis, CA.
Ann Emerg Med. 2023 Sep;82(3):369-380. doi: 10.1016/j.annemergmed.2023.02.014. Epub 2023 Apr 5.
Some patients with acute pulmonary embolism (PE) will suffer adverse clinical outcomes despite being low risk by clinical decision rules. Emergency physician decisionmaking processes regarding which low-risk patients require hospitalization are unclear. Higher heart rate (HR) or embolic burden may increase short-term mortality risk, and we hypothesized that these variables would be associated with an increased likelihood of hospitalization for patients designated as low risk by the PE Severity Index.
This was a retrospective cohort study of 461 adult emergency department (ED) patients with a PE Severity Index score of fewer than 86 points. Primary exposures were the highest observed ED HR, most proximal embolus location (proximal vs distal), and embolism laterality (bilateral vs unilateral PE). The primary outcome was hospitalization.
Of 461 patients meeting inclusion criteria, most (57.5%) were hospitalized, 2 patients (0.4%) died within 30 days, and 142 (30.8%) patients were at elevated risk by other criteria (Hestia criteria or biochemical/radiographic right ventricular dysfunction). Variablesassociated with an increased likelihood of admission were highest observed ED HR of ≥110 beats/minute (vs HR <90 beats/min) (adjusted odds ratio [aOR] 3.11; 95% confidence interval [CI] 1.07 to 9.57), highest ED HR 90 to 109 (aOR 2.03; 95% CI 1.18-3.50) and bilateral PE (aOR 1.92; 95% CI 1.13 to 3.27). Proximal embolus location was not associated with the likelihood of hospitalization (aOR 1.19; 95% CI 0.71 to 2.00).
Most patients were hospitalized, often with recognizable high-risk characteristics not accounted for by the PE Severity Index. Highest ED HR of ≥90 beats/min and bilateral PE were associated with a physician's decision for hospitalization.
尽管临床决策规则将某些急性肺栓塞（PE）患者归类为低危，但仍有部分患者出现不良临床结局。急诊医师对于哪些低危患者需要住院治疗的决策过程尚不清楚。较高的心率（HR）或栓塞负荷可能会增加短期死亡率风险，我们假设这些变量与 PE 严重指数评分归类为低危的患者的住院可能性增加相关。
这是一项回顾性队列研究，纳入了 461 名 PE 严重指数评分＜86 分的成年急诊患者。主要暴露因素为最高观察到的急诊 HR、最接近的栓子位置（近端 vs. 远端）和栓塞侧别（双侧 vs. 单侧 PE）。主要结局为住院治疗。
在符合纳入标准的 461 名患者中，大多数（57.5%）被收治住院，2 名患者（0.4%）在 30 天内死亡，142 名患者（30.8%）因其他标准（Hestia 标准或生化/影像学右心室功能障碍）而被归类为高危。与入院可能性增加相关的变量包括最高观察到的急诊 HR≥110 次/分钟（vs. HR＜90 次/分钟）（校正比值比[aOR]3.11；95%置信区间[CI]1.07 至 9.57）、90 至 109 次/分钟（aOR 2.03；95%CI 1.18 至 3.50）和双侧 PE（aOR 1.92；95%CI 1.13 至 3.27）。近端栓子位置与住院可能性无关（aOR 1.19；95%CI 0.71 至 2.00）。
大多数患者被收治住院，其中许多患者存在 PE 严重指数未考虑到的可识别高危特征。最高急诊 HR≥90 次/分钟和双侧 PE 与医生决定住院治疗相关。
