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Short-term outcomes of pulmonary embolism: A National Perspective.

ABSTRACT: BACKGROUND:Pulmonary embolism (PE) is associated with significant morbidity and mortality in hospitalized patients. Real time data on 90-day mortality, bleeding, and readmission is sparse. METHODS:The study cohort was derived from the National Readmission Data (NRD) 2013 to 2014. PE was identified using International Classification of Diseases, ninth Revision (ICD-9-CM) code 415.11/3/9 in the primary diagnosis field. Any admission within 90 days of primary admission was considered a 90-day readmission. Readmission etiologies were identified by ICD-9 code in the primary diagnosis field. Co-primary outcomes were 90-day readmission and 90-day mortality. RESULTS:We identified 260 614 patients with primary admission PE, 55 659 (21.36%) patients were readmitted within 90 days. Most of them were of old age (age ? 65 years: 49.04%) and females (52.78%). Among the etiologies of readmission pulmonary disorders (22.94%) (Including recurrent PE 7.33%), malignancies (8.31%), and bleeding disorders (6.75%) were the most important causes of 90-day readmissions. On multivariate analysis, higher readmission rates and 90 days mortality were seen in patients with heart failure, chronic pulmonary disease, Anemia, malignancy, and with higher Charlson score. Patients with longer length of stay during primary admission and who discharged to short/long-term facility were more likely get readmitted and die in 90 days. Paradoxically, obese patients showed an inverse relationship with co-primary outcomes. CONCLUSIONS:Older female patients were more likely to have a pulmonary embolism. High-risk groups such as heart failure, chronic pulmonary disease, anemia, and malignancy need to be given extra attention to prevent worse outcomes.

SUBMITTER: Shah P

PROVIDER: S-EPMC6490021 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Short-term outcomes of pulmonary embolism: A National Perspective.

Shah Purav P Arora Shilpkumar S Kumar Varun V Sharma Surina S Shah Harshil H Tripathi Byomesh B Sharma Purnima P Sharma Ravina R Savani Sejal S Qureshi Muhammad Raheel MR Faruqi Ibrahim I

Clinical cardiology 20180924 9

<h4>Background</h4>Pulmonary embolism (PE) is associated with significant morbidity and mortality in hospitalized patients. Real time data on 90-day mortality, bleeding, and readmission is sparse.<h4>Methods</h4>The study cohort was derived from the National Readmission Data (NRD) 2013 to 2014. PE was identified using International Classification of Diseases, ninth Revision (ICD-9-CM) code 415.11/3/9 in the primary diagnosis field. Any admission within 90 days of primary admission was considered ...[more]

PMID: 30117162

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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.

Project description:ObjectiveDevelop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria.MethodsWe used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801).ResultsLogistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome.ConclusionsPE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.

Project description:RationaleSocietal 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.ObjectiveTo 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.MethodsRetrospective 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.ResultsWe 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.ConclusionsTrans-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.

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Short-term outcomes of pulmonary embolism: A National Perspective.

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Short-term outcomes of pulmonary embolism: A National Perspective.

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