Abstract：
OBJECTIVE: Home treatment is considered safe in acute pulmonary embolism (PE) patients selected by a validated triage tool (e.g. simplified PE severity index score or Hestia rule), but there is uncertainty regarding the applicability in underrepresented subgroups. The aim was to evaluate the safety of home treatment by performing an individual patient-level data meta-analysis.
METHODS: Ten prospective cohort studies or randomized controlled trials were identified in a systematic search, totalling 2694 PE patients treated at home (discharged within 24 h) and identified by a predefined triage tool. The 14- and 30-day incidences of all-cause mortality and adverse events (combined endpoint of recurrent venous thromboembolism, major bleeding, and/or all-cause mortality) were evaluated. The relative risk (RR) for 14- and 30-day mortalities and adverse events is calculated in subgroups using a random effects model.
RESULTS: The 14- and 30-day mortalities were 0.11% [95% confidence interval (CI) 0.0-0.24, I2 = 0) and 0.30% (95% CI 0.09-0.51, I2 = 0). The 14- and 30-day incidences of adverse events were 0.56% (95% CI 0.28-0.84, I2 = 0) and 1.2% (95% CI 0.79-1.6, I2 = 0). Cancer was associated with increased 30-day mortality [RR 4.9; 95% prediction interval (PI) 2.7-9.1; I2 = 0]. Pre-existing cardiopulmonary disease, abnormal troponin, and abnormal (N-terminal pro-)B-type natriuretic peptide [(NT-pro)BNP] at presentation were associated with an increased incidence of 14-day adverse events [RR 3.5 (95% PI 1.5-7.9, I2 = 0), 2.5 (95% PI 1.3-4.9, I2 = 0), and 3.9 (95% PI 1.6-9.8, I2 = 0), respectively], but not mortality. At 30 days, cancer, abnormal troponin, and abnormal (NT-pro)BNP were associated with an increased incidence of adverse events [RR 2.7 (95% PI 1.4-5.2, I2 = 0), 2.9 (95% PI 1.5-5.7, I2 = 0), and 3.3 (95% PI 1.6-7.1, I2 = 0), respectively].
CONCLUSIONS: The incidence of adverse events in home-treated PE patients, selected by a validated triage tool, was very low. Patients with cancer had a three- to five-fold higher incidence of adverse events and death. Patients with increased troponin or (NT-pro)BNP had a three-fold higher risk of adverse events, driven by recurrent venous thromboembolism and bleeding.
METHODS: Ten prospective cohort studies or randomized controlled trials were identified in a systematic search, totalling 2694 PE patients treated at home (discharged within 24 h) and identified by a predefined triage tool. The 14- and 30-day incidences of all-cause mortality and adverse events (combined endpoint of recurrent venous thromboembolism, major bleeding, and/or all-cause mortality) were evaluated. The relative risk (RR) for 14- and 30-day mortalities and adverse events is calculated in subgroups using a random effects model.
RESULTS: The 14- and 30-day mortalities were 0.11% [95% confidence interval (CI) 0.0-0.24, I2 = 0) and 0.30% (95% CI 0.09-0.51, I2 = 0). The 14- and 30-day incidences of adverse events were 0.56% (95% CI 0.28-0.84, I2 = 0) and 1.2% (95% CI 0.79-1.6, I2 = 0). Cancer was associated with increased 30-day mortality [RR 4.9; 95% prediction interval (PI) 2.7-9.1; I2 = 0]. Pre-existing cardiopulmonary disease, abnormal troponin, and abnormal (N-terminal pro-)B-type natriuretic peptide [(NT-pro)BNP] at presentation were associated with an increased incidence of 14-day adverse events [RR 3.5 (95% PI 1.5-7.9, I2 = 0), 2.5 (95% PI 1.3-4.9, I2 = 0), and 3.9 (95% PI 1.6-9.8, I2 = 0), respectively], but not mortality. At 30 days, cancer, abnormal troponin, and abnormal (NT-pro)BNP were associated with an increased incidence of adverse events [RR 2.7 (95% PI 1.4-5.2, I2 = 0), 2.9 (95% PI 1.5-5.7, I2 = 0), and 3.3 (95% PI 1.6-7.1, I2 = 0), respectively].
CONCLUSIONS: The incidence of adverse events in home-treated PE patients, selected by a validated triage tool, was very low. Patients with cancer had a three- to five-fold higher incidence of adverse events and death. Patients with increased troponin or (NT-pro)BNP had a three-fold higher risk of adverse events, driven by recurrent venous thromboembolism and bleeding.
摘要：
目的：通过有效的分诊工具（例如简化的PE严重程度指数评分或Hestia规则）选择的急性肺栓塞（PE）患者，家庭治疗被认为是安全的，但是在代表性不足的子组中的适用性存在不确定性。目的是通过进行个体患者水平的数据荟萃分析来评估家庭治疗的安全性。
方法：在系统搜索中确定了10项前瞻性队列研究或随机对照试验，共有2694名PE患者在家治疗（24小时内出院），并通过预定义的分诊工具进行识别。全因死亡率和不良事件的14天和30天发生率（复发性静脉血栓栓塞症的联合终点，大出血,和/或全因死亡率）进行了评估。使用随机效应模型在亚组中计算14天和30天死亡率和不良事件的相对风险（RR）。
结果：14天和30天死亡率分别为0.11%[95%置信区间(CI)0.0-0.24,I2=0)和0.30%(95%CI0.09-0.51,I2=0)。14天和30天不良事件发生率分别为0.56%（95%CI0.28-0.84，I2=0）和1.2%（95%CI0.79-1.6，I2=0）。癌症与30天死亡率增加相关[RR4.9;95%预测间隔(PI)2.7-9.1;I2=0]。先前存在的心肺疾病，异常肌钙蛋白,和异常（N末端前体）B型利钠肽[（NT-pro）BNP]在报告中与14天不良事件的发生率增加相关[RR3.5（95％PI1.5-7.9，I2=0），2.5（95%PI1.3-4.9，I2=0），和3.9（95%PI1.6-9.8，I2=0），分别]，但不是死亡率。在30天，癌症,异常肌钙蛋白,和异常（NT-pro）BNP与不良事件发生率增加相关[RR2.7（95％PI1.4-5.2，I2=0），2.9（95%PI1.5-5.7，I2=0），和3.3（95%PI1.6-7.1，I2=0），分别]。
结论：家庭治疗的PE患者的不良事件发生率，由经过验证的分类工具选择，非常低。癌症患者的不良事件和死亡发生率高出3至5倍。肌钙蛋白或（NT-pro）BNP升高的患者发生不良事件的风险高三倍，由反复的静脉血栓栓塞和出血引起。
方法：在系统搜索中确定了10项前瞻性队列研究或随机对照试验，共有2694名PE患者在家治疗（24小时内出院），并通过预定义的分诊工具进行识别。全因死亡率和不良事件的14天和30天发生率（复发性静脉血栓栓塞症的联合终点，大出血,和/或全因死亡率）进行了评估。使用随机效应模型在亚组中计算14天和30天死亡率和不良事件的相对风险（RR）。
结果：14天和30天死亡率分别为0.11%[95%置信区间(CI)0.0-0.24,I2=0)和0.30%(95%CI0.09-0.51,I2=0)。14天和30天不良事件发生率分别为0.56%（95%CI0.28-0.84，I2=0）和1.2%（95%CI0.79-1.6，I2=0）。癌症与30天死亡率增加相关[RR4.9;95%预测间隔(PI)2.7-9.1;I2=0]。先前存在的心肺疾病，异常肌钙蛋白,和异常（N末端前体）B型利钠肽[（NT-pro）BNP]在报告中与14天不良事件的发生率增加相关[RR3.5（95％PI1.5-7.9，I2=0），2.5（95%PI1.3-4.9，I2=0），和3.9（95%PI1.6-9.8，I2=0），分别]，但不是死亡率。在30天，癌症,异常肌钙蛋白,和异常（NT-pro）BNP与不良事件发生率增加相关[RR2.7（95％PI1.4-5.2，I2=0），2.9（95%PI1.5-5.7，I2=0），和3.3（95%PI1.6-7.1，I2=0），分别]。
结论：家庭治疗的PE患者的不良事件发生率，由经过验证的分类工具选择，非常低。癌症患者的不良事件和死亡发生率高出3至5倍。肌钙蛋白或（NT-pro）BNP升高的患者发生不良事件的风险高三倍，由反复的静脉血栓栓塞和出血引起。
