肺栓塞严重指数对急性肺栓塞预后的预测价值

目的:探讨肺栓塞严重指数(PESI)对急性肺栓塞(PE)的预测价值。方法:利用PESI对6家医院2005年01月～2009年12月期间住院PE患者30天内的预后转归进行回顾性分析。结果:共收集PE患者185例,30d死亡率为11.9%,Ⅰ级0%、Ⅱ级2.4%、Ⅲ级6.5%、Ⅳ级15%、Ⅴ级22.5%,随PESI危险级别上升而显著升高(P0.001)。PESI预测死亡率准确度显示敏感性及阴性预测值均高。结论:利用PESI对PE进行危险分层,可较准确地判断PE预后,进而指导临床早期干预,改善预后。     

Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism

BackgroundRisk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition.ObjectivesIn this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality.MethodsThis was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30-day mortality.ResultsThe pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-of-care ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37–31.86), RV enlargement (OR 4.02, 95% CI 1.43–11.34), and a McConnell sign (OR 2.79, 95% CI 1.09–7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74–53.32).ConclusionIn patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.     

Point-of-Care Focused Cardiac Ultrasound for Prediction of Pulmonary Embolism Adverse Outcomes

Background

In patients with pulmonary embolism (PE), right ventricular strain (RVS) on transthoracic echocardiography by Cardiology has been shown to be an independent predictor of 30-day adverse outcomes. However, it is not known how emergency practitioner-performed point-of-care focused cardiac ultrasound (FOCUS) with assessment for RVS compares with other prognostic methods in the Emergency Department (ED).

Objectives

To determine whether RVS on FOCUS is a significant predictor of in-hospital adverse outcomes when compared to other risk factors and scoring systems.

Methods

Retrospective chart review of patients who were diagnosed with PE and had a FOCUS examination during January 1, 2007 through January 1, 2011 in an urban, academic center with a well-developed ultrasound program. Adverse outcomes were defined as shock, respiratory failure requiring intubation, death, recurrent venous thromboembolism, transition to higher level of care, or major bleeding during hospital admission. Statistical analysis included univariate and multivariate analysis to assess for prognostic significance.

Results

One hundred sixty-one patients were included in the final analysis. A total of 25 (16%) patients had an adverse outcome during hospitalization. On univariate analysis, only the presence of altered mental status conferred a higher positive likelihood ratio (6.4 vs. 4.0) than RVS, whereas absence of RVS had the lowest negative likelihood ratio (0.45). On multivariate analysis, RVS and cardiopulmonary disease were the only predictors of adverse outcomes that achieved statistical significance, with odds ratio of 9.2 and 3.4, respectively.

Conclusion

In this retrospective chart review, a FOCUS examination for RVS performed by emergency care practitioners of varying experience level was a significant predictor of in-hospital adverse outcomes among patients diagnosed with PE in the ED. Future research should be directed at exploring ways to incorporate RVS assessment into ED prognostic models for pulmonary embolism.     

肺栓塞严重指数联合心肌肌钙蛋白I对早期血压正常急性肺栓塞预后的预测价值

目的：探讨肺栓塞严重指数（PESI）、心肌钙蛋白I（cTnI）对早期血压正常急性肺栓塞（APE）预后的预测价值。方法：利用PESI评分、cTnI定量对2009年01月-2012年12月确诊的早期血压正常APE患者进行分组．观察30d内不良事件发生情况,分析不同分层方法对早期血压正常APE患者预后的预测价值。结果：165例患者入选,PESI高危103例（62．4％）、低危62例（37．6％）,cTnI阳性98例（59．4％）、cTnI阴性67例（40．6％）,PESI高危且cTnI阳性75例（45．5％）、PESI低危且cTnI阴性42例（25．5％）。PESI高危组或cTnI阳性组（89％）和阴性预测值（97％）．联合分层对不良预后预测的敏感性93％、阳性预测值（98％）和阳性似然比9．57。结论：PESI、cTnI对早期血压正常的APE30d内预后有一定预测价值,二者联合可提高对30d内低危风险患者识别的敏感性及特异性。     

Tricuspid Annular Plane Systolic Excursion (TAPSE) for Risk Stratification and Prognostication of Patients with Pulmonary Embolism

BackgroundThe categorization of pulmonary embolism (PE) as non-massive, sub-massive, and massive helps guide acute management. The presence of right ventricular (RV) strain differentiates sub-massive from non-massive PEs. Unlike laboratory markers and electrocardiogram changes, the classic parameters used in the echocardiographic diagnosis of RV strain have a technical component that is operator-dependent.ObjectiveThis narrative review will describe the physiologic effects of a PE on the RV and how this affects prognosis. It will summarize the literature evaluating the accuracy and prognostic ability of tricuspid annular plane systolic excursion (TAPSE) in the echocardiographic assessment of RVfunction. The review will describe the appeal of TAPSE for this purpose, provide cutoff measurements, and then illustrate how to perform the technique itself, while offering associated pearls and pitfalls in this bedside evaluation.DiscussionRV function and dynamics undergo acute changes in the setting of a PE. RV dysfunction predicts poor outcomes in both the short and long term. However, RV strain is difficult to capture on echocardiography due to the chamber's complex geometric shape and contraction. From the apical four-chamber window, TAPSE offers a quantitative measure that is more easily performed with high interobserver reliability for evaluating systolic RV contraction. This measurement carries prognostic value in patients diagnosed with PE.ConclusionsAlong with other more qualitative echocardiographic parameters, TAPSE can be used as a simple quantitative measure of RV dysfunction for differentiating sub-massive from non-massive PEs. This categorization helps guide acute management and disposition.     

Direct Comparison of the Diagnostic Accuracy of Fifty Protein Biological Markers of Pulmonary Embolism for Use in the Emergency Department

Objectives: Pulmonary embolism (PE) is associated with abnormal concentrations of many proteins involved in inflammation, hemostasis, and vascular injury. The authors quantified the diagnostic accuracy of a battery of protein biological markers for the detection of PE in emergency department (ED) patients. Methods: A random and a consecutive sample of ED patients evaluated for PE were prospectively enrolled at two academic EDs between August 2005 and April 2006. A plasma sample was obtained at enrollment, and all patients were followed by telephone and medical record review at 90 days for the development of venous thromboembolism (VTE) defined as PE or deep venous thrombosis (DVT), requiring the consensus of two of three blinded physician reviewers. Measurements of potential biological markers were performed by technicians blinded to the study objectives. The diagnostic accuracy of each biological marker was determined by the area under the receiver operating characteristic (ROC) curve. Results: Fifty potential biological markers were measured in 304 ED patients, including 22 patients (7%, 95% confidence interval [CI] = 4% to 10%) with VTE. Fourteen biological markers demonstrated an area under the curve (AUC) with the lower limit of the 95% CI ≥ 0.5. Of these, three demonstrated an AUC ≥ 0.7: D‐dimer (0.90), C‐reactive protein (CRP; 0.78), and myeloperoxidase (MPO; 0.78). Conclusions: From 50 candidate biological markers, only D‐dimer, CRP, and MPO demonstrated sufficient diagnostic accuracy to suggest potential utility as biological marker of PE.     

Motion Analysis of Right Ventricular Dysfunction Under Mild or Moderate Pressure Overload Caused by Acute Pulmonary Embolism

Acute pulmonary embolism (APE) is the third most common cause of death in the United States. Appearing as a sudden blockage in a major pulmonary artery, APE may cause mild, moderate or severe right ventricular (RV) overload. Although severe RV overload produces diagnostically obvious RV mechanical failure, little progress has been made in gaining a clinical and biophysical understanding of moderate and mild acute RV overload and its impact on RV functionality. In the research described here, we conducted a pilot study in pigs using echocardiography and observed the following abnormalities in RV functionality under acute mild or moderate RV overload: (i) occurrence of paradoxical septal motion with “waving” dynamics; (ii) decrease in local curvature of the septum (p < 0.01); (iii) lower positive correlation between movement of the RV free wall and movement of the septum (p < 0.05); (iv) slower rate of RV fractional area change (p < 0.05); and (v) decrease in movement stability, particularly in the middle of the septum (p < 0.05).     

Use of the d-dimer for Detecting Pulmonary Embolism in the Emergency Department

Background

Assessment for pulmonary embolism (PE) in the emergency department (ED) remains complex, involving clinical decision tools, blood tests, and imaging.

组织多普勒超声评价急性肺动脉栓塞患者右室功能的研究

目的　探讨应用组织多普勒成像 (TDI)评价急性肺动脉栓塞 (PE)患者右室功能的价值。方法　应用TDI观察13例应用螺旋CT诊断的急性PE患者治疗前后右室功能参数的改变 ,并分析TDI参数与肺动脉栓塞指数之间的关系。结果　急性PE患者治疗后右室侧壁基底段VE较治疗前显著增高 ( 10 .2 7± 3 .83 )cm/svs ( 13 .48± 3 .82 )cm/s ,P <0 .0 5 ,VA显著降低 ( 2 3 .16± 6.89)cm/svs ( 17.88± 3 .79)cm/s ,P <0 .0 5 ,右室侧壁各节段VE/VA增高显著 ;右室侧壁基底段VE/VA与螺旋CT肺动脉阻塞指数之间显著相关 (r =-0 .45 9,P <0 .0 5 )。结论　TDI参数对急性PE患者病变程度及疗效判定有一定的临床应用价值。     

经胸超声心动图诊断急性肺动脉栓塞的价值

目的　探讨经胸超声心动图 (transthoracic echocardiography,TTE)对急性肺动脉栓塞 (acute pulmonary embolism,APE)的诊断价值。方法　分析 16例确诊为 APE患者的 TTE表现 ,与肺动脉造影、肺核素扫描及计算机体层摄影对照。结果　超声直接检出主肺动脉及左、右肺动脉主干近段血栓者 6例 ,均被 CT或肺动脉造影证实 ,其中超声还直接检出右室内血栓 3例、右房内血栓 1例 ;本组资料具有右心负荷过重超声征象者 12例 (其中包括超声直接检出血栓的 6例 ) ,CT或核素肺灌注 /通气扫描提示为双肺多发性大面积栓塞 ;TTE检查大致正常者 4例 ,但核素肺灌注 /通气扫描或者 CT均提示为肺段或亚段栓塞。结论　经胸超声心动图可发现主肺动脉、左右肺动脉干内血栓直接提示肺动脉栓塞 ,或根据右心负荷过重表现并结合临床表现间接提示肺栓塞的可能 ,但对肺段或亚段栓塞者超声不能作出或排除诊断。     

心脏生物标志物联合肺栓塞严重程度指数对急性肺栓塞症诊断及危险分层的研究

目的检测急性肺栓塞（APE）患者血浆中B型钠尿肽（BNP）和肌钙蛋白I（cTnI）的浓度,研究肺栓塞严重程度指数（PESI）、cTnI、BNP对APE诊断及预后的预测价值。方法选取2010年1月-2013年1月确诊的共96例APE患者,同时选取同期非APE对照者50例。对入选者进行肺栓塞严重指数（PESI）评分,据分值大小分为低危组、中危组、高危组;根据cTnI与BNP结果分组为阳性组及阴性组。分析PESI、cTnI和BNP在APE患者诊断与危险分层的预测价值。结果 APE患者中低危、中危与高危各组大面积、次大面积APE构成比随组别增高而升高（P〈0.01）;cTnI阳性组大面积、次大面积APE占82.9%,cTnI阴性组非大面积APE占81.9%;BNP阳性组大面积、次大面积APE占73.3%,BNP阴性组非大面积APE占86.3%。cTnI、BNP阳性组右心功能不全、心源性休克及死亡的发生率明显高于阴性组（P〈0.01）。结论联合检测cTnI、BNP结合PESI评分在APE的诊断和危险分层中具有重要意义。     

Risk Factors for Serious Underlying Pathology in Adult Emergency Department Nontraumatic Low Back Pain Patients

Background

Nontraumatic low back pain (LBP) is a common emergency department (ED) complaint and can be caused by serious pathologies that require immediate intervention or that lead to death.

Objective

The primary goal of this study is to identify risk factors associated with serious pathology in adult nontraumatic ED LBP patients.

Methods

We conducted a health records review and included patients aged ≥ 16 years with nontraumatic LBP presenting to an academic ED from November 2009 to January 2010. We excluded those with previously confirmed nephrolithiasis and typical renal colic presentation. We collected 56 predictor variables and outcomes within 30 days. Outcomes were determined by tracking computerized patient records and performance of univariate analysis and recursive partitioning.

Results

There were 329 patients included, with a mean age of 49.3 years; 50.8% were women. A total of 22 (6.7%) patients suffered outcomes, including one death, five compression fractures, four malignancies, four disc prolapses requiring surgery, two retroperitoneal bleeds, two osteomyelitis, and one each of epidural abscess, cauda equina, and leaking abdominal aortic aneurysm graft. Risk factors identified for outcomes were: anticoagulant use (odds ratio [OR] 15.6; 95% confidence interval [CI] 4.2–58.5), decreased sensation on physical examination (OR 6.9; CI 2.2–21.2), pain that is worse at night (OR 4.3; CI 0.9–20.1), and pain that persists despite appropriate treatment (OR 2.2; CI 0.8–5.6). These four predictors identified serious pathology with 91% sensitivity (95% CI 70–98%) and 55% specificity (95% CI 54–56%).

Conclusion

We successfully identified risk factors associated with serious pathology among ED LBP patients. Future prospective studies are required to derive a robust clinical decision rule.     

B型利钠肽对急性肺栓塞预后预测价值的Meta分析

目的探讨B型利钠肽(B-type natriuretic peptide,BNP)对急性肺栓塞(acute pulmonary embolism,APE)患者短期全死因死亡的预测价值。方法计算机检索PubMed、EMbase、Cochrane图书馆临床对照试验资料库、CBM网络版和CNKI等数据库,检索时间均从建库至2010年3月,收集BNP和N-终端前BNP(N-terminal pro-B-type natriuretic peptide,NT-proBNP)水平升高对APE患者预后影响的队列研究,对符合纳入标准的临床研究进行质量评价和资料提取后,采用RevMan 5.0和MetaDisc软件进行Meta分析。结果共纳入16项研究,合计1126例患者。9个研究报道了BNP水平,7个研究报道了NT-proBNP水平,各组间异质性较小(P=0.94,I2=0;P=0.99,I2=0),且无临床异质性,故将BNP或NT-proBNP升高视为同一结果。Meta分析结果显示:BNP或NT-proBNP水平升高对于短期全死因死亡预测价值的SEN合并为0.89,SPE合并为0.52,+LR合并为1.87,-LR合并为0.20,PPV为0.16,NPV为0.98,SROC曲线下面积为0.8305,SE(AUC)=0.0335。结论 BNP水平升高可以帮助鉴别死亡率高的急性肺栓塞患者,而BNP水平正常的患者阴性预测值高则有助于医生识别出那些不良事件发生可能性较低的患者,以便有选择性地进行患者随访。     

慢性阻塞性肺疾病合并右心功能不全患者血清超敏肌钙蛋白Ⅰ浓度的变化

目的 观察慢性阻塞性肺疾病(COPD)合并右心功能不全患者不同阶段及治疗前后血清超敏肌钙蛋白I(hs-cTn I)浓度的变化,并对其临床意义进行探讨.方法 将120例COPD合并右心功能不全患者按右心功能不全分期分组:即阶段A(Ⅰ组,n=58)、阶段B(Ⅱ组,n=32)、阶段C(Ⅲ组,n=16)、阶段D(Ⅳ组,n=14).比较各组治疗前后血清hs-cTn I浓度、Pa02和PaC02.结果 Ⅰ、Ⅱ组治疗前后血清hs-cTn I浓度差异无统计学意义(P＞0.05).治疗后血清hs-cTnI浓度:Ⅲ组、Ⅳ组较治疗前明显降低(P＜0.01),Ⅳ组高于Ⅲ组(P＜0.01),Ⅲ、Ⅳ组高于Ⅰ、Ⅱ组(P＜0.01).经Pearson相关分析,hs-cTnI浓度与Pa02值呈负相关(r=-0.326,P＜0.01).结论 血清hs-cTnI浓度可以反映COPD患者右心功能不全的严重程度,且与缺氧程度相关.可以作为评估右心功能不全失代偿期治疗效果的指标.     

Best Clinical Practice: Controversies in Outpatient Management of Acute Pulmonary Embolism

Background

Pulmonary embolism (PE) is a common condition managed in the emergency department (ED), with a wide range of morbidity and mortality. Patients are classically admitted for treatment and monitoring of anticoagulation.

CT阻塞指数对急性肺栓塞严重性的评价

【目的】研究CT阻塞指数评价急性肺栓塞（APE）严重性的价值。【方法】根据APE患者的临床表现,把45例APE患者分为两组：严重APE组（14例）和非严重APE组（31例）。在CT肺血管造影上,根据肺动脉内栓子阻塞部位和程度计算CT阻塞指数（Az值）。使用U检验法评价严重APE组和非严重APE组之间的CT阻塞指数的差异;使用ROC曲线分析CT阻塞指数诊断APE严重性的准确度。【结果】严重APE组的CT阻塞指数（中位数45％）高于非严重APE组的CT阻塞指数（中位数25％）（P〈0．01）。阻塞指数的Az值〉0．5。【结论】在CT上测量阻塞指数可以定量评价APE患者的严重性。