The safety and efficacy of systemic versus catheter-based therapies: application of a prognostic model by a pulmonary embolism response team.
The safety and efficacy of systemic versus catheter-based therapies: application of a prognostic model by a pulmonary embolism response team.
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全身治疗与导管治疗的安全性和有效性：肺栓塞反应小组预后模型的应用。
DOI：
10.1007/s11239-021-02576-3
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发表时间：
2022
影响因子：
4
通讯作者：
Cameron,ScottJ
中科院分区：
文献类型：
--
作者：
Iskandar,Jean-Pierre;Hariri,Essa;Kanaan,Christopher;Kassis,Nicholas;Kamran,Hayaan;Sese,Denise;Wright,Colin;Marinescu,Mark;Cameron,ScottJ
肺栓塞反应小组（PERT）决定使用抗凝（AC）联合或不联合全身溶栓（ST）或导管导向治疗（CDT）治疗肺栓塞（PE），这是对积极结局和安全性的期望之间的平衡。我们的主要目的是开发一个预测模型，用于预测PERT管理的高风险或中等风险PE患者的院内死亡率，同时对该模型进行外部验证。我们的次要目的是比较ST和CDT在该队列中的相对安全性和有效性。回顾性评价了2014年6月至2020年1月期间在克利夫兰临床基金会和罗切斯特大学住院的经PERT治疗的急性高风险或中风险PE患者。按治疗策略对各组进行分层。主要结局是住院死亡率，次要结局是大出血。使用推导队列建立了预测主要结局的逻辑回归模型，内部验证采用100倍自举法。进行外部验证并计算受试者工作曲线下面积（AUC）。在纳入的549例患者中，421例仅接受AC，71例接受ST，64例接受CDT。大出血的预测因素包括ESC风险分类、PESI评分、缺氧、血流动力学不稳定和血清乳酸。相对于ST，CDT有降低死亡率的趋势，但出血风险增加（OR = 0.42; 95% CI [0.15，1.17]和OR = 2.14; 95% CI [0.9，5.06]）。在衍生机构队列的多变量logistic回归模型中，院内死亡率的预测因素为年龄、癌症、需要血管加压药的血流动力学不稳定和NT-proBNP升高（AUC = 0.86）。使用验证机构队列（AUC = 0.88）验证该模型。我们报告了一个外部验证的模型，用于预测PERT管理的PE患者的院内死亡率。PERT决定对这些患者启动CDT或ST对死亡率或大出血没有影响，但这些干预措施的长期疗效需要阐明。
The decision by pulmonary embolism response teams (PERTs) to utilize anticoagulation (AC) with or without systemic thrombolysis (ST) or catheter-directed therapies (CDT) for pulmonary embolism (PE) is a balance between the desire for a positive outcome and safety. Our primary aim was to develop a predictive model of in-hospital mortality for patients with high- or intermediate-risk PE managed by PERT while externally validating this model. Our secondary aim was to compare the relative safety and efficacy of ST and CDT in this cohort. Consecutive patients hospitalized between June 2014 and January 2020 at the Cleveland Clinic Foundation and The University of Rochester with acute high- or intermediate-risk PE managed by PERT were retrospectively evaluated. Groups were stratified by treatment strategy. The primary outcome was in-hospital mortality, and secondary outcome was major bleeding. A logistic regression model to predict the primary outcome was built using the derivation cohort, with 100-fold bootstrapping for internal validation. External validation was performed and the area under the receiver operating curve (AUC) was calculated. Of 549 included patients, 421 received AC alone, 71 received ST, and 64 received CDT. Predictors of major bleeding include ESC risk category, PESI score, hypoxia, hemodynamic instability, and serum lactate. CDT trended towards lower mortality but with an increased risk of bleeding relative to ST (OR = 0.42; 95% CI [0.15, 1.17] and OR = 2.14; 95% CI [0.9, 5.06] respectively). In the multivariable logistic regression model in the derivation institution cohort, predictors of in-hospital mortality were age, cancer, hemodynamic instability requiring vasopressors, and elevated NT-proBNP (AUC = 0.86). This model was validated using the validation institution cohort (AUC = 0.88). We report an externally-validated model for predicting in-hospital mortality in patients with PE managed by PERT. The decision by PERT to initiate CDT or ST for these patients had no impact on mortality or major bleeding, yet the long-term efficacy of these interventions needs to be elucidated.