Dataset Information

Echocardiogram in the Evaluation of Hemodynamically Stable Acute Pulmonary Embolism: National Practices and Clinical Outcomes.

ABSTRACT:

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.

SUBMITTER: Cohen DM

PROVIDER: S-EPMC5955052 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Objectives:Acute pulmonary embolism can be a life-threatening condition with a high mortality. The treatment choice is a matter of debate. The early and late outcomes of patients treated with surgical pulmonary embolectomy for acute pulmonary embolism in a single center were analyzed. Methods:All consecutive patients operated on for pulmonary embolism between January 2002 and March 2017 were reviewed. Patient demographics and pre- and postoperative clinical data were retrieved from our patient registry, and risk factors for in-hospital and long-term mortality were identified. Results:In total, 175 patients (mean age 59±3 years, 50% male) were operated on for acute pulmonary embolism. In-hospital mortality was 19% (34/175). No differences were found when comparing surgery utilizing a beating heart or cardioplegic arrest. Risk factors for in-hospital mortality were age >70 years [odds ratio (OR) 4.8, confidence interval (CI) 1.7-13.1, p=0.002], body surface area <2 m2 (OR 4.7, CI 1.6-13.7, p=0.004), preoperative resuscitation (OR 14.1, CI 4.9-40.8, p<0.001), and the absence of deep vein thrombosis (OR 9.6, CI 2.5-37.6, p<0.001). Follow-up was 100% complete with a 10-year survival rate of 66.4% in 141/175 patients surviving to discharge. Once discharged from hospital, none of the risk factors identified for in-hospital mortality were relevant for long-term survival except the absence of deep vein thrombosis (OR 3.2, CI 1.2-8.2, p=0.019). The presence of malignancy was a relevant risk factor for long-term mortality (OR 4.3, CI 1.8-10.3, p=0.001). Conclusion:Surgical pulmonary embolectomy as a therapy for acute pulmonary embolism demonstrates excellent short- and long-term results in patients with an otherwise life-threatening disease, especially in younger patients with a body surface area >2 m2 and pulmonary embolism caused by deep vein thrombosis. Pulmonary embolectomy should therefore not be reserved as a treatment of last resort for clinically desperate circumstances.