Luijten Dieuwke, Abbel Denise, Cannegieter Suzanne C, Eikenboom Jeroen, den Exter Paul L, Gussekloo Jacobijn, Huisman Menno V, van Mens Thijs E, Tahir Lara, Trompet Stella, Mooijaart Simon P, Klok Frederikus A
Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands.
Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands; Department of Internal Medicine-Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands.
J Thromb Haemost. 2025 Feb;23(2):588-599. doi: 10.1016/j.jtha.2024.10.015. Epub 2024 Oct 23.
Managing older patients with acute pulmonary embolism (PE) is challenging due to their underrepresentation in clinical trials, comorbidities, and increased complication risk.
To evaluate risk assessment and management outcomes in older patients with PE focusing on home and reperfusion treatment.
A retrospective analysis was conducted on patients aged 70 years or older diagnosed with acute PE at an academic medical center (2015-2022).
In total, 242 patients with a mean age of 77 years were included. All 59 patients with negative Hestia criteria were discharged ≤24 hours, and in total, 81 patients (35%) received home treatment. Among these 14-day mortality and recurrent venous thromboembolism were 0% and major bleeding occurred in 1.3% (1 patient, 95% CI: 0.11-6.1). European Society of Cardiology risk classification showed 9 low-risk (3.9%), 199 intermediate-risk (87%), and 20 high-risk (8.8) patients with PE. In 5 of the 20 high-risk patients, hypotension was mainly caused by another condition, that is, sepsis. Eight high-risk patients received reperfusion therapy. The 14-day mortality rate was 51% in high-risk patients (95% CI: 27-71); 5 of 8 patients receiving reperfusion treatment died within 5 days. Patients with an Acute Presenting Older Patient score of ≥45% had higher 14-day mortality (28%; 95% CI: 12-46) compared with <45% (3.2%; 95% CI: 0.85-8.3; hazard ratios: 10.2; 95% CI: 2.6-39).
Selecting for home treatment using Hestia criteria was safe for older patients with PE in our cohort. Mortality in the high-risk group was high also when receiving reperfusion treatment. The European Society of Cardiology risk classification and Acute Presenting Older Patient score identified patients at higher mortality risk, suggesting their potential utility in clinical decision-making.
由于老年急性肺栓塞（PE）患者在临床试验中的代表性不足、合并症以及并发症风险增加，对其进行管理具有挑战性。
评估老年PE患者的风险评估和管理结果，重点关注居家治疗和再灌注治疗。
对在一家学术医疗中心诊断为急性PE的70岁及以上患者进行回顾性分析（2015 - 2022年）。
共纳入242例平均年龄为77岁的患者。所有59例符合赫斯提亚标准阴性的患者在≤24小时内出院，共有81例患者（35%）接受了居家治疗。在这些患者中，14天死亡率和复发性静脉血栓栓塞率均为0%，主要出血发生率为1.3%（1例患者，95%置信区间：0.11 - 6.1）。欧洲心脏病学会风险分类显示，9例（3.9%）为低风险、199例（87%）为中风险、20例（8.8%）为高风险PE患者。在20例高风险患者中，有5例低血压主要由其他疾病引起，即脓毒症。8例高风险患者接受了再灌注治疗。高风险患者的14天死亡率为51%（95%置信区间：27 - 71）；8例接受再灌注治疗的患者中有5例在5天内死亡。急性老年患者表现评分≥45%的患者14天死亡率（28%；95%置信区间：12 - 46）高于评分<45%的患者（3.2%；95%置信区间：0.85 - 8.3；风险比：10.2；95%置信区间：2.6 - 39）。
在我们的队列中，使用赫斯提亚标准选择居家治疗对老年PE患者是安全的。高风险组患者接受再灌注治疗时死亡率也很高。欧洲心脏病学会风险分类和急性老年患者表现评分识别出了死亡率较高的患者，表明它们在临床决策中具有潜在用途。
