RESUMO
BACKGROUND: In patients with acute pulmonary embolism (PE), rapid and accurate risk assessment is paramount in selecting the appropriate treatment strategy. The prognostic value of right ventricular dysfunction (RVD) assessed by multidetector CT (MDCT) in normotensive patients with PE has lacked adequate validation. METHODS: The study defined MDCT-assessed RVD as a ratio of the RV to the left ventricle short axis diameter greater than 0.9. Outcomes assessed through 30 days after the diagnosis of PE included all-cause mortality and 'complicated course', which consisted of death from any cause, haemodynamic collapse or recurrent PE. RESULTS: MDCT detected RVD in 533 (63%) of the 848 enrolled patients. Those with RVD on MDCT more frequently had echocardiographic RVD (31%) than those without RVD on MDCT (9.2%) (p<0.001). Patients with RVD on MDCT had significantly higher brain natriuretic peptide (269±447 vs 180±457 pg/ml, p<0.001) and troponin (0.10±0.43 vs 0.03±0.24 ng/ml, p=0.001) levels in comparison with those without RVD on MDCT. During follow-up, death occurred in 25 patients with and in 13 patients without RVD on MDCT (4.7% vs 4.3%; p=0.93). Those with and those without RVD on MDCT had a similar frequency of complicated course (3.9% vs 2.3%; p=0.30). CONCLUSIONS: The PROgnosTic valuE of CT study showed a relationship between RVD assessed by MDCT and other markers of cardiac dysfunction around the time of PE diagnosis, but did not demonstrate an association between MDCT-RVD and prognosis.
Assuntos
Tomografia Computadorizada Multidetectores/métodos , Embolia Pulmonar/diagnóstico por imagem , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Embolia Pulmonar/complicações , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Medição de Risco/métodos , Espanha/epidemiologia , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/etiologia , Disfunção Ventricular Direita/mortalidadeRESUMO
BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have a modified clinical presentation of venous thromboembolism (VTE) but also a worse prognosis than non-COPD patients with VTE. As it may induce therapeutic modifications, we evaluated the influence of the initial VTE presentation on the 3-month outcomes in COPD patients. METHODS: COPD patients included in the on-going world-wide RIETE Registry were studied. The rate of pulmonary embolism (PE), major bleeding and death during the first 3 months in COPD patients were compared according to their initial clinical presentation (acute PE or deep vein thrombosis (DVT)). RESULTS: Of the 4036 COPD patients included, 2452 (61%; 95% CI: 59.2-62.3) initially presented with PE. PE as the first VTE recurrence occurred in 116 patients, major bleeding in 101 patients and mortality in 443 patients (Fatal PE: first cause of death). Multivariate analysis confirmed that presenting with PE was associated with higher risk of VTE recurrence as PE (OR, 2.04; 95% CI: 1.11-3.72) and higher risk of fatal PE (OR, 7.77; 95% CI: 2.92-15.7). CONCLUSIONS: COPD patients presenting with PE have an increased risk for PE recurrences and fatal PE compared with those presenting with DVT alone. More efficient therapy is needed in this subtype of patients.
Assuntos
Doença Pulmonar Obstrutiva Crônica/mortalidade , Embolia Pulmonar/mortalidade , Sistema de Registros , Tromboembolia Venosa/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Comorbidade , Feminino , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Medição de Risco , Análise de Sobrevida , Taxa de Sobrevida , Adulto JovemRESUMO
BACKGROUND: Exacerbations are a major cause of disability, hospital admissions, and increased healthcare costs in patients with chronic obstructive pulmonary disease (COPD). This study investigated the clinical outcomes of outpatients with moderate to severe exacerbated COPD and their related costs. METHODS: An observational study on the outcomes of ambulatory exacerbations of COPD was conducted. The course of the exacerbation was evaluated at a follow-up visit at 4 weeks. A cost analysis that encompassed the use of healthcare resources for treatment of the exacerbation was performed. RESULTS: A total of 260 patients were included, with a mean age of 68.3 years and a mean FEV1 (% predicted) of 58.9 %. Twenty-two percent of patients had significant cardiovascular comorbidity. The most frequently prescribed antibiotics were moxifloxacin in 137 cases and amoxicillin-clavulanate in 50 cases. The rate of failure at 4 weeks was 12.5 %, with no differences between the two most prescribed antibiotics; however, patients treated with moxifloxacin had symptoms for 1.9 fewer days (P = 0.01). The mean cost of the exacerbation was
Assuntos
Antibacterianos/economia , Antibacterianos/uso terapêutico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/economia , Idoso , Combinação Amoxicilina e Clavulanato de Potássio/economia , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Compostos Aza/economia , Compostos Aza/uso terapêutico , Estudos de Coortes , Custos e Análise de Custo , Feminino , Fluoroquinolonas , Seguimentos , Volume Expiratório Forçado/fisiologia , Custos de Cuidados de Saúde , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Moxifloxacina , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Quinolinas/economia , Quinolinas/uso terapêutico , Falha de Tratamento , Resultado do TratamentoRESUMO
Though studies have identified clinical variables that predict adverse events in patients with acute pulmonary embolism (PE), they have typically not differentiated short-term from long-term predictors. This multicenter prospective cohort study included consecutive outpatients with objectively confirmed symptomatic acute PE. We analyzed the incidence and time course of death, venous thromboembolism (VTE) recurrence, and major bleeding, and we compared event rates during short-term (first week) and long-term (3 months) follow-up after the diagnosis of PE. We also assessed risk factors for short-term mortality. During the first three months after diagnosis of PE, 142 of 1,338 (10.6%) patients died. Thirty-six deaths (2.7%) occurred during the first week after diagnosis of PE, and 61.1% of these were due to PE. Thirty-eight patients (2.8%) had recurrent VTE during the three-month follow-up, though none of the recurrences occurred during the first week after diagnosis of PE. During the three-month follow-up, major bleeding occurred in 48 patients (3.6%). Twenty-one (1.6%) major bleeds occurred during the first week of follow-up, and nine of these were fatal. Short-term mortality was significantly increased in patients who initially presented with systolic arterial hypotension (odds ratio [OR] 3.35; 95% CI, 1.51-5.41) or immobilization due to a medical illness (OR 2.89; 95% confidence interval [CI], 1.31-6.39). In conclusion, during the first week after the diagnosis of PE, death and major bleeding occur more frequently than recurrent VTE. Patients with systolic arterial hypotension and immobilization at the time of PE diagnosis had an increased risk of short-term mortality.
Assuntos
Anticoagulantes/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológico , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Repouso em Cama/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Missouri , Razão de Chances , Pacientes Ambulatoriais , Estudos Prospectivos , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Recidiva , Medição de Risco , Fatores de Risco , Espanha , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/complicações , Tromboembolia Venosa/mortalidade , Adulto JovemRESUMO
OBJECTIVE: To assess the performance of two prognostic models in predicting short-term mortality in patients with pulmonary embolism (PE). SUBJECTS AND METHODS: We compared the test characteristics of two prognostic models for predicting 30-day outcomes (mortality, thromboembolic recurrences, and major bleeding) in a cohort of 599 patients with objectively confirmed PE. Patients were stratified into the PE severity index (PESI) risk classes I-V and the Geneva low-risk and high-risk strata. We compared the discriminatory power of both prognostic models. RESULTS: The PESI classified fewer patients as low risk (strata I and II) [36%; 216 of 599 patients; 95% confidence interval (CI), 32 to 40%] compared to the Geneva prediction rule (84%; 502 of 599 patients; 95% CI, 81 to 87%) [p < 0.0001]. Using either prediction rule, the low-risk groups showed statistically relevant 30-day mortality difference (PESI, 0.9%; 95% CI, 0.3 to 2.2; vs Geneva, 5.6%; 95% CI, 3.6 to 7.6) [p < 0.0001], although nonfatal recurrent venous thromboembolism or major bleeding rates were statistically similar (PESI, 2.8%; 95% CI, 0.6 to 5.0%; vs Geneva, 4.2%; 95% CI, 2.4 to 5.9%). The area under the receiver operating characteristic curve was higher for the PESI (0.76; 95% CI, 0.69 to 0.83) than for the Geneva score (0.61; 95% CI, 0.51 to 0.71) [p = 0.002]. CONCLUSIONS: The PESI quantified the prognosis of patients with PE better than the Geneva score. This study demonstrated that PESI can select patients with very low adverse event rates during the initial days of acute PE therapy and assist in selecting patients for treatment in the outpatient setting.
Assuntos
Assistência Ambulatorial , Técnicas de Apoio para a Decisão , Seleção de Pacientes , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/mortalidade , Índice de Gravidade de Doença , Doença Aguda , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Estudos de Coortes , Feminino , Heparina de Baixo Peso Molecular/efeitos adversos , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Embolia Pulmonar/fisiopatologia , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: To identify patients with a low short-term risk of complications following acute pulmonary thromboembolism. PATIENTS AND METHODS: A prospective multicenter study was conducted in 8 Spanish hospitals; 681 consecutive outpatients diagnosed with pulmonary thromboembolism were enrolled. Clinically significant variables were weighted using coefficients derived from a logistic regression model in order to optimize the diagnostic performance of a clinical prediction rule to predict the following complications within 10 days of acute pulmonary thromboembolism: death, recurrent thromboembolism, and major or minor bleeding. RESULTS: Forty-three patients (6.3%) had 51 complications. These included 33 deaths, 12 major bleeding episodes, and 6 minor bleeding episodes. The clinical variables used in the prediction rule were assigned the following scores: recent major bleeding episode and cancer with metastasis, 4 points each; creatinine levels of over 2 mg/dL, 3 points; cancer without metastasis and immobility due to a recent medical condition, 2 points each; and absence of surgery in the past 2 months and an age of over 60 years, 1 point each. A risk score of 2 or less, obtained by 47.8% of patients, indicated a low short-term risk of developing complications following pulmonary thromboembolism. The area under the receiver operating characteristic curve for the prediction rule was 0.75 (95% confidence interval [CI], 0.67-0.83). For this cutoff point, sensitivity was 82.9% (95% CI, 68.7-91.5) and the likelihood ratios for a positive and negative test result were 1.63 (95% CI, 1.39-1.92), and 0.35 (95% CI, 0.18-0.69), respectively. CONCLUSIONS: Our clinical prediction rule could be useful for identifying patients with a low risk of complications in the 10 days following acute pulmonary thromboembolism. Those patients would be eligible for consideration for outpatient treatment.
Assuntos
Embolia Pulmonar/epidemiologia , Doença Aguda , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Embolia Pulmonar/mortalidade , Curva ROC , Recidiva , Medição de Risco , Fatores de RiscoRESUMO
INTRODUCTION: The influence of the clinical syndromes of pulmonary embolism (PE) on clinical outcome has not been evaluated. PATIENTS AND METHODS: The Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) is an ongoing registry of consecutive patients with acute venous thromboembolism. In this study, all enrolled patients with acute PE without preexisting cardiac or pulmonary disease were classified into three clinical syndromes: pulmonary infarction, isolated dyspnea, or circulatory collapse. Their clinical characteristics, laboratory findings, and 3-month outcomes were compared. RESULTS: As of January 2005, 4,145 patients with acute, symptomatic, objectively confirmed PE have been enrolled in RIETE. Of them, 3,391 patients (82%) had no chronic lung disease or heart failure: 1,709 patients (50%) had pulmonary infarction, 1,083 patients (32%) had isolated dyspnea, and 599 patients (18%) had circulatory collapse. Overall, 149 patients (4.4%) died during the first 15 days of therapy: 2.5% with pulmonary infarction, 6.2% with isolated dyspnea (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7 to 3.8), and 6.5% with circulatory collapse (OR, 2.7; 95% CI, 1.7 to 4.2). From days 16 to 90, 31 patients had recurrent PE; 5 of 14 patients (36%) with pulmonary infarction died of their new PE, compared with 5 of 10 patients (50%) with isolated dyspnea, and all 7 patients (100%) with circulatory collapse. CONCLUSIONS: PE patients with pulmonary infarction (50% of the whole series) had a significantly lower mortality rate both during initial therapy and after discharge.
Assuntos
Dispneia/etiologia , Embolia Pulmonar/diagnóstico , Choque/diagnóstico , Trombose Venosa/diagnóstico , Doença Aguda , Idoso , Intervalos de Confiança , Dispneia/tratamento farmacológico , Dispneia/mortalidade , Feminino , Seguimentos , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Razão de Chances , Prognóstico , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/mortalidade , Recidiva , Sistema de Registros , Choque/tratamento farmacológico , Choque/mortalidade , Análise de Sobrevida , Síndrome , Terapia Trombolítica , Trombose Venosa/tratamento farmacológico , Trombose Venosa/mortalidadeRESUMO
BACKGROUND AND OBJECTIVE: Mortality, recurrences and hemorrhages are the most serious early complications of pulmonary embolism (PE). We intended to ascertain the frequency and mechanisms of complications within the first 10 days after PE was diagnosed. PATIENTS AND METHOD: We included patients suspected of suffering PE between December 2003 and August 2004 from 8 hospitals. We performed a multicenter observational prospective study of 8 Spanish hospitals with consecutive outpatients diagnosed with PE. Database of clinical variables: computerized Registry of Patients with Venous Thromboembolism (RIETE). Statistic analysis included chi2 and Student's t test to compare the 2 groups of patients (with and without complications). RESULTS: Six hundred eighty one patients were included, 336 men and 345 women (mean age 66 and 70, respectively). During the first 10 days, 33 (4.8%) of them died, and 22 (3.2%) had an hemorrhage yet no recurrences appeared. Previous immobilization and the presence of respiratory failure, cancer or renal failure were significantly associated with early complications while previous surgery and thoracic pain were not associated with those. CONCLUSIONS: Early complications and some of the associated factors were in agreement with published data. Other situations such as previous surgery or thoracic pain appeared to be protective factors.
Assuntos
Embolia Pulmonar/complicações , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/mortalidadeRESUMO
BACKGROUND: Echocardiography remains a clinically useful screening test for chronic thromboembolic pulmonary hypertension (CTEPH) in patients with a history of pulmonary embolism (PE). To devise an effective screening strategy, the definition of a high-risk group is necessary. METHODS: We examined a total of 744 patients with acute symptomatic pulmonary embolism (PE) who were enrolled in a Spanish multicenter study. Patients were monitored every 6months during the first two years, and then once a year thereafter. Transthoracic echocardiography was used to screen patients with a clinical suspicion of CTEPH during follow-up. Pulmonary arterial hypertension was defined as an estimated pulmonary artery systolic pressure (PAP)>50mm Hg. The index thromboembolic episode was considered severe if: (a) the patient was immobilized for medical reasons; or (b) systolic blood pressure was less than 90mm Hg; or (c) troponin T values were above the reference range. RESULTS: The incidence of PAP>50mm Hg at 36months was 8.3% (95% confidence interval=4.6%-14.5%). Statistical analysis showed a highly significant association between a severe index thromboembolic episode and the subsequent detection of PAP>50mm Hg on echocardiography, with high positive likelihood ratio (2.40) and negative predictive value (>0.97). CONCLUSIONS: Patients with a severe index thromboembolic episode would constitute a high-risk group for the development of CTEPH. This group of patients should be subjected to a strict follow-up protocol.
Assuntos
Hipertensão Pulmonar/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Artérias/diagnóstico por imagem , Doença Crônica , Feminino , Seguimentos , Hospitalização , Humanos , Hipertensão Pulmonar/epidemiologia , Incidência , Pulmão/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/epidemiologia , Fatores de Risco , Espanha/epidemiologia , UltrassonografiaRESUMO
BACKGROUND: Limited data exist on the feasibility of providing outpatient care to patients with acute pulmonary embolism (PE). METHODS: We conducted a multicenter randomized clinical trial in acute symptomatic PE to compare the efficacy and safety of early discharge versus standard hospitalization. A clinical prediction rule was used to identify low-risk patients. All patients were followed for three months. The primary outcomes were venous thromboembolic recurrences, major and minor bleeding, and overall mortality. RESULTS: One hundred and thirty two low-risk patients with acute symptomatic PE were randomized to early discharge (n=72) or standard hospitalization (n=60). Overall mortality was 4.2% (95% CI, 0.5-8.9) in the early discharge group and 8.3% (95% CI, 1.1-15) in the standard hospitalization group (Relative Risk (RR) 0.5; 95% confidence interval [CI], 0.12-2.01). Non-fatal recurrences were 2.8% (95% CI, 1.1-6.6) in the early discharge group and 3.3% (95% CI, 1.3-8%) in the standard hospitalization group (RR 0.8; 95% CI, 0.12-5.74). The rates of clinically relevant bleeding were 5.5% in the early discharge group and 5% in the standard hospitalization group (P=0.60). Short-term mortality was 2.8% (95% CI, 0.8-9.6%) in the early discharge group as compared with 0% in the standard hospitalization group. Based on the rate of short-term death in a carefully selected population, the study was suspended. CONCLUSIONS: In spite of the number of complications in patients with acute symptomatic PE randomized to standard hospitalization or early discharge did not differ significantly. The rate of short-term mortality was unexpectedly high in a (a priori) low-risk group of patients with acute PE. The accuracy of clinical prediction scores needs to be validated in well designed clinical trials. (ClinicalTrials.gov number, NCT00214929.).