Identificación de pacientes de riesgo intermedio con tromboembolia de pulmón aguda sintomáticameta-análisis de datos individuales de 6 estudios

Resumen

The identification of normotensive patients with acute pulmonary embolism (PE) who might be candidates for thrombolytic therapy (i.e., intermediate-risk group) is a major challenge. However, there is no explicit prognostic model that accurately identifies these patients.Methods. We combined individual patient data from six prospective cohort studies involving 2,874 normotensive patients with acute PE. We developed a prognostic model for intermediate-risk PE based on the clinical presentation and the assessment of right ventricular (RV) dysfunction and myocardial injury. We used a composite of PE-related death, haemodynamic collapse or recurrent PE within the 30-days of follow-up as the main outcome measure.Results. The primary outcome occurred in 198 (6.9%) patients. Predictors of 30-day PE-related complications included low systolic blood pressure (adjusted odds ratio [ORadj] 2.45; 95% confidence interval [CI], 1.50 to 3.99), higher heart rate (ORadj 1.87; 95% CI, 1.31 to 2.69), elevated cardiac troponin (ORadj 2.49; 95% CI, 1.71 to 3.69), and RV dysfunction (ORadj 2.28; 95% CI, 1.58 to 3.29). We used these variables to construct a multidimensional 7-point risk index in which higher scores indicate a higher risk of PE-specific complications; the odds ratio for complications per one-point increase in the score was 1.55 (95% CI, 1.43 to 1.68; P < 0.001). The model identified three stages (I, II, and III) with 30-day PE-related complication rates of 4.2%, 10.8%, and 29.2%, respectively.Conclusions. A simple multidimensional grading system may assist clinicians in identifying intermediate-risk PE and in providing quantitative guidance for decision-making in PE care