Kueng Cedrine, Boesing Maria, Giezendanner Stéphanie, Leuppi Jörg Daniel, Lüthi-Corridori Giorgia
University Institute of Internal Medicine, Cantonal Hospital Baselland, CH-4410 Liestal, Switzerland.
Faculty of Medicine, University of Basel, CH-4056 Basel, Switzerland.
J Clin Med. 2024 Oct 13;13(20):6103. doi: 10.3390/jcm13206103.
Diagnosing acute pulmonary embolism (PE) is challenging due to its wide range of symptoms and numerous differential diagnoses. Medical professionals must balance performing all essential examinations and avoiding unnecessary testing. This study aimed to retrospectively audit the diagnosis and treatment of acute PE at a Swiss public teaching hospital to determine the adherence to current guidelines and to identify the factors associated with the delayed initiation of anticoagulation in PE patients. In this retrospective observational cohort study, we included all adult patients hospitalized with PE at the Cantonal Hospital Baselland (KSBL) between November 2018 and October 2020, where the diagnosis was made within the first twelve hours of their arrival to the emergency department (ED). LASSO regression was employed to identify clinical characteristics associated with delayed anticoagulation initiation. A total of 197 patients were included (mean age: 70 years, 54% female). The audit revealed that diagnostic workup was conducted according to guidelines in 57% of cases. Often, D-dimer levels were measured although not strictly necessary (70%). Pretest probability was assessed and documented using the Wells or Geneva score in only 3% of patients, and risk assessment via the Pulmonary Embolism Severity Index (PESI) score was documented in 21% of patients. The median time from ED arrival to CT scan was 120 min (IQR 89.5-210.5), and the median time to anticoagulation initiation was 193 min (IQR 145-277). Factors identified by LASSO associated with delayed anticoagulation included prolonged time from ED arrival to CT scan, the presence of distended jugular veins on examination, ED arrival in the morning, and presenting symptoms of weakness or tiredness. Complementary leg ultrasound was performed in 57% of patients, with 38% of these cases lacking prior clinical examination for deep vein thrombosis. The duration of the anticoagulation treatment was not specified in the discharge report for 17% of patients. A medical follow-up after discharge was recommended in 75% of the patients. In conclusion, while the management of PE at the KSBL generally adheres to high standards, there are areas for improvement, particularly in the morning performance, the use of a pretest probability assessment, D-dimer measurement, risk assessment via the PESI score, the performance of complementary leg ultrasounds, clarification of the anticoagulation duration, and follow-up management.
由于急性肺栓塞（PE）症状范围广泛且鉴别诊断众多，其诊断具有挑战性。医学专业人员必须在进行所有必要检查和避免不必要检测之间取得平衡。本研究旨在回顾性审核瑞士一家公立教学医院急性PE的诊断和治疗情况，以确定对当前指南的遵循情况，并识别与PE患者抗凝治疗延迟启动相关的因素。在这项回顾性观察性队列研究中，我们纳入了2018年11月至2020年10月期间在巴塞尔州立医院（KSBL）因PE住院的所有成年患者，这些患者在抵达急诊科（ED）的前12小时内确诊。采用套索回归来识别与抗凝治疗延迟启动相关的临床特征。共纳入197例患者（平均年龄：70岁，54%为女性）。审核显示，57%的病例诊断检查是按照指南进行的。通常，尽管并非严格必要，但仍有70%的病例检测了D-二聚体水平。仅3%的患者使用Wells或Geneva评分评估并记录了预测试概率，21%的患者记录了通过肺栓塞严重程度指数（PESI）评分进行的风险评估。从ED抵达至CT扫描的中位时间为120分钟（四分位间距89.5 - 210.5），抗凝治疗启动的中位时间为193分钟（四分位间距145 - 277）。套索回归识别出与抗凝治疗延迟相关的因素包括从ED抵达至CT扫描的时间延长、检查时颈静脉扩张、早晨抵达ED以及出现虚弱或疲劳症状。57%的患者进行了辅助腿部超声检查，其中3种情况在进行深静脉血栓形成的临床检查。17%的患者出院报告中未明确抗凝治疗的持续时间。75%的患者出院后建议进行医学随访。总之，虽然KSBL对PE的管理总体上符合高标准，但仍有改进空间，特别是在早晨的工作表现、预测试概率评估的使用、D-二聚体测量、通过PESI评分进行的风险评估、辅助腿部超声检查的实施、抗凝持续时间的明确以及随访管理方面。
