背景:在过去的几年中,在急性肺栓塞(PE)管理中,多学科肺栓塞反应小组(PERTs)的概念出现了越来越多的多样性和复杂性.
目的:研究德国一所大学中心PERT的组成和增加的临床价值。
方法:超过4年(01/2019-11/2022),确诊为PE的患者被纳入一项前瞻性单中心队列研究(PERTMainz).我们调查了PERT的组成,并进行了比较,在倾向得分匹配后,在我们的医科大学中心开始PERT之前和之后的急性PE患者。主要结局是院内PE相关死亡率。
结果:从2019年到2022年,登记了88例急性PE患者并做出PERT决定。其中,13例(14.8%)患者在住院期间死亡。通过PERT评估的患者中位年龄为68岁;48.9%为女性,21.7%患有恶性肿瘤。76.1%的患者存在右心室功能障碍。总的来说,42.0%被归类为中高风险PE,11.4%被归类为高风险PE。首次接触PERT主要来自急诊科(33.3%)和重症监护病房(30.0%),其次是胸痛单位(21.3%)和常规病房(12.0%)。医学专业的参与率表明,几乎所有PERT会诊都包括心脏病专家(100%)或心脏/血管外科医生(98.6%)。其次是放射科医师(95.9%)和麻醉科医师(87.8%)。与PERT时代相比,根据ESC2019指南,PERT前时代的更多患者被分类为简化肺栓塞严重程度指数(sPESI)≥1(78.4%vs71.6%)和高危PE(18.2%vs.11.4%)。在前PERT时代,与PERT时代相比,低和中低PE患者接受更频繁的高级再灌注治疗,如全身溶栓或手术栓子切除术(10.7%vs.2.5%)。发现PERT前患者的全因死亡率和PE相关死亡率高得多(31.8%vs.14.8%)与PERT时代的患者相比(22.7%与13.6%)。在通过将参数包括为年龄进行倾向匹配(1:1)之后,性别,sPESI,和ESC风险等级,单变量回归分析表明,基于PERT决策的PE管理与全因死亡率风险降低相关(OR,0.37[95CI0.18-0.77];p=0.009)。对于与PE相关的死亡率,观察到减少的趋势(OR,0.54[95CI0.24-1.18];p=0.121)。
结论:在急性PE患者中实施PERT与全因死亡率风险较低相关。需要进一步进行大型前瞻性研究来探索PERT对临床结果的影响。
BACKGROUND: Over the last few years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in managing acute pulmonary embolism (PE).
OBJECTIVE: To investigate PERT\'s composition and added clinical value in a university center in Germany.
METHODS: Over 4 years (01/2019-11/2022), patients with confirmed PE were enrolled in a prospective single-center cohort study (PERT Mainz). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE before and after the initiation of PERT at our Medical University Centre. The primary outcome was in-hospital PE-related mortality.
RESULTS: From 2019 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a median age of 68; 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 76.1% of all patients. In total, 42.0% were classified as intermediate-high-risk PE and 11.4% as high-risk PE. First PERT contact mainly originated from emergency departments (33.3%) and intensive care units (30.0%), followed by chest pain units (21.3%) and regular wards (12.0%). The participation rate of medical specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT consultations, followed by radiologists (95.9%) and anesthesiologists (87.8%). Compared to the PERT era, more patients in the pre-PERT era were classified as simplified pulmonary embolism severity index (sPESI) ≥ 1 (78.4% vs 71.6%) and as high-risk PE according to ESC 2019 guidelines (18.2% vs. 11.4%). In the pre-PERT era, low- and intermediate-low patients with PE received more frequently advanced reperfusion therapies such as systemic thrombolysis or surgical embolectomy compared to the PERT era (10.7% vs. 2.5%). Patients in the pre-PERT were found to have a considerably higher all-cause mortality and PE-related mortality rate (31.8% vs. 14.8%) compared to patients in the PERT era (22.7% vs. 13.6%). After propensity matching (1:1) by including parameters as age, sex, sPESI, and ESC risk classes, univariate regression analyses demonstrated that the PE management based on a PERT decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p = 0.009). For PE-related mortality, a tendency for reduction was observed (OR, 0.54 [95%CI 0.24-1.18]; p = 0.121).
CONCLUSIONS: PERT implementation was associated with a lower risk of all-cause mortality rate in patients with acute PE. Large prospective studies are needed further to explore the impact of PERTs on clinical outcomes.