超声心动图在评估血流动力学稳定的急性肺栓塞的分析 | 引经据典 [1] · 协和呼吸
本期解读
急性肺栓塞患者
（血流动力学稳定）
需要常规进行心脏超声检查吗？
作者：
Cohen DM, et al.
翻译：
北京协和医院呼吸内科 孙宇新 黄慧
文献来源：
Ann Am Thorac Soc. 2018 May 5;15(5): 581–588.
PMID: 29298088
DOI: 10.1513/AnnalsATS.201707-577OC
背景及目的
关于是否在血流动力学稳定的急性肺栓塞患者中常规开展经胸超声心动图（TTE）检查评价是否存在右心室损伤尚未达成共识，本回顾性研究拟通过分析在这类患者中早期开展TTE与患者预后的相关性。
方 法
回顾性分析纳入Premier Inc.数据库中，2008年至2011年期间20%左右的美国急性肺栓塞住院病例（血液动力学稳定，≥18岁）。
结 果
纳入来自363家医院的血流动力学稳定急性肺栓塞住院病例64037例（平均年龄61.7岁，54%为女性，68%为白人），26925 例行TTE。不同医院间TTE的使用率差异很大（0-89%，中位数为41.4%)。医院TTE的使用率与这些患者风险校正死亡率（OR值0.88，95%可信区间[CI]0.69-1.13）、溶栓药使用率（OR值1.28，95%CI0.84-1.96）不相关。高TTE使用率的医院，患者ICU住院率（OR值1.57，95%CI1.18-2.07）、住院时长（RR值1.08，95%CI1.03-1.15）和治疗费用（RR值1.15，95%CI1.07-1.23）更高。不过，TTE检查的这些患者中，接受溶栓治疗（OR值5.58，95%CI4.40-7.09）和发生严重出血事件（OR值1.37，95%CI1.24-1.51）的比例更高。
结 论
在美国，不同医院之间对于是否在血流动力学稳定的急性肺栓塞患者中开展TTE差异很大。高TTE使用率的医院并未能改变患者的死亡率，但医疗成本就明显提高了，这也进一步支持2016年ACCP肺栓塞指南中提出的，对于血流动力学稳定的患者，选择性、而非常规行TTE检查。
原文摘要
RATIONALE:
Societal guideline recommendations vary with regard to the role of routine trans-thoracic echocardiography to screen for right ventricular strain in patients with hemodynamically stable acute pulmonary embolism.
OBJECTIVE:
To characterize national patterns in use of early trans-thoracic echocardiography for the evaluation of patients with hemodynamically stable acute pulmonary embolism and determine associations between trans-thoracic echocardiography use and patient outcomes.
METHODS:
Retrospective cohort study using Premier, Inc. database of approximately 20% of patients hospitalized in the United States with hemodynamically stable acute pulmonary embolism between 2008 and 2011. Multivariable, risk-adjusted hierarchical regression models were used to evaluate hospital variation in use of trans-thoracic echocardiography for pulmonary embolism and associations between hospital trans-thoracic echocardiography rates and patient outcomes. Patient-level trans-thoracic echocardiography exposure was used in sensitivity analyses.
RESULTS:
We identified 64,037 patients (mean age, 61.7 years; 54% women; 68% white) hospitalized at 363 U.S. hospitals. Trans-thoracic echocardiography rates for hemodynamically stable acute pulmonary embolism varied widely among hospitals (median trans-thoracic echocardiography rate, 41.4%; range, 0-89%; interquartile range, 32.7-51.7%). Hospital rates of trans-thoracic echocardiography were not associated with significant differences in risk-adjusted mortality (trans-thoracic echocardiography rate quartile 4 vs. quartile 1: odds ratio, 0.88; 95% confidence interval, 0.69-1.13) or use of thrombolytics (odds ratio, 1.28; 95% confidence interval, 0.84-1.96), but rates of intensive care unit admission (odds ratio, 1.57; 95% confidence interval, 1.18-2.07), hospital length of stay (relative risk, 1.08; 95% confidence interval, 1.03-1.15), and costs (relative risk, 1.15; 95% confidence interval, 1.07-1.23) were significantly higher at hospitals with high trans-thoracic echocardiography rates. Analyses of patient-level trans-thoracic echocardiography exposure produced similar results, except with higher rates of thrombolysis (odds ratio, 5.58; 95% confidence interval, 4.40-7.09) and bleeding (odds ratio, 1.37; 95% confidence interval, 1.24-1.51) among patients receiving trans-thoracic echocardiography.
CONCLUSIONS:
Trans-thoracic echocardiography use in the evaluation of patients with hemodynamically stable acute pulmonary embolism varied widely between hospitals. Hospitals with high rates of pulmonary embolism-associated trans-thoracic echocardiography use did not achieve different patient mortality outcomes but had higher resource use and costs. Our findings support the 2016 American College of Chest Physicians guidelines for management of pulmonary embolism, which recommend selective, rather than routine, use of trans-thoracic echocardiography to risk stratify patients with hemodynamically stable pulmonary embolism.
作者介绍
黄 慧
副主任医师 硕士生导师
擅长：结节病、各种弥漫性间质性肺病、特殊肺部感染（如诺卡菌、放线菌等）的临床和基础研究。
中华医学会呼吸病分会间质病学组组员；《中华结核和呼吸杂志》通讯编委。作为主要研究者参与多个抗纤维化药物治疗特发性肺纤维化的国内外多中心临床试验。以第一作者、通讯作者在国内外核心期刊发表论文20余篇；主持国自然青年基金1项，参与多项国自然、科技部重大专项。
文字来源：孙宇新 黄慧
栏目负责：黄慧
版面编辑：陈珂琪
图片来源：部分来源于网络，如有侵权，请联系删除
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