Basitleștirilmiș Pulmoner Emboli Ağırlık İndeks (SPESI) Skoru 0 Olan Olgularda İleri Risk Sınıflaması Gereksiz Mi?

Amaç: Avrupa Kardiyoloji Derneği (ESC), risk sınıflama modeline göre, akut pulmoner tromboemboli (PTE) olgularında eğer basitleștirilmiș pulmoner emboli ağırlık indeksi (sPESI) 0 ise ileri risk sınıflaması gereksizdir. Bu olgular erken taburcu edilebilir veya uygun olanlar ayaktan tedavi edilebilir. Bu çalıșmanın üç amacı vardı. Birincisi; sPESI 0 olduğu halde ileri risk sınıflaması ile orta riskli saptanan olguların oranı, ikincisi; bu durum için risk faktörlerinin saptanması ve üçüncüsü de risk sınıflaması değișikliğinin klinik üzerindeki etkilerinin saptanmasıdır. Gereç ve Yöntem: Tek merkezde yapılan bu prospektif kuhort çalıșmada olguların hepsine sPESI skorlarından bağımsız olarak bașvuru anında eko ve kardiyak biomarkerlar ile ileri risk sınıflaması yapıldı. sPESI skoru 0 olan olgular çalıșmaya dahil edildi. Bulgular: PTE tanısı alan toplam 109 olgu vardı. Bunlardan 33’ünde sPESI skoru 0 idi. İleri risk sınıflaması ile bu 33 olgunun %60,6’sı düșük , %30,3’ü orta düșük ve %9,1’i orta yüksek riskti. Olguların hepsi yatarak tedavi edildi. Takipte İki (%6,1) olguda solunum yetmezliği geliști ve bu olgulardan birisinde hipotansyon gelișmesi nedeniyle trombolitik uygulandı. D-dimer değeri (p=0.017) ve ana pulmoner arterlerde trombus olması (p=0.000) orta riskli grupta istatistiksel olarak anlamlı derecede daha yüksekti. Sonuç: Sadece sPESI skoruna göre ayaktan tedavi veya erken taburculuk kararı verilmesi özellikle ana pulmoner arterlerde emboli olan veya D-dimer değeri 3600 ng/ml üzerinde olan ve aslında unstabil olan olguların taburculuğuna neden olabilir.

Is Advanced Risk Stratification Unnecessary In Patients with Simplified Pulmonary Embolism Severity Index (sPESI) of 0?

Aim: The European Society Cardiology guidelines state that advanced risk stratification is unnecessary in patients with simplified pulmonary embolism severity index (sPESI) of 0 because it does not affect treatment decision. Also, these patients can be discharged early or treated as outpatients if feasible. There were three aims of the present study. The first was to determine the rate of patients with sPESI of 0 but classified into intermediate risk category with advanced risk stratification. is the second was to determine the clinical impact of this risk classification change. And the third was to define risk factors for this condition.Patients and Methods: This is prospective single-center cohort study. All patients underwent advanced risk stratification at admission independent from the sPESI score. Patients with a sPESI score 0 were included.Results: There were 33 patients with sPESI score of 0. With advanced risk stratification; 60.6% of patients were low risk, 30.3% were intermediate low risk and 9.1% were intermediate-high risk. In 2 (6.1%) patients, respiratory failure developed. One of these patients became hypotensive and required thrombolytic treatment. D-dimer value (p=0.017) and thrombus in main pulmonary arteries (p=0.000) were statistically significantly high in intermediate risk group.Conclusions: Advanced risk stratification in sPESI 0 patients has an impact on management decisions. Early discharge or outpatient treatment decisions based on sPESI alone may cause the discharge of unstable patients especially in patients with main pulmonary artery thromboembolism or D-dimer level over 3600 ng/ml.

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28. Myles PS, Leslie K, McNeil J, Forbes A, Chan MTV. Bispectral index monitoring to prevent awareness during anaesthesia: the b-aware randomised controlled trial. Lancet 2004; 363: 1757-1763.
27. Avidan MS, Zhang L, Burnside BA, et.al. Anesthesia awareness and the bispectral index. N Engl J Med 2008; 358: 1097-1108.
26. Rautiainen P. Alfentanil infusion for sedation in infants and small children during cardiac catheterization. Can J naesth 1991; 38: 980-984.
25. Tosun Z, Akin A, Guler G, Esmaoglu A, Boyaci A. Dexmedetomidineketamine and propofol-ketamine combinations for anesthesia in spontaneously breathing pediatric patients undergoing cardiac catheterization. J Cardiothorac Vasc Anesth 2006; 20: 515-519.
24. Mukhtar AM, Obayah EM, Hassona AM.The use of dexmedetomidine in pediatric cardiac surgery. Anesth Analg 2006; 103: 52-56.
23. Tobias JD, Berkenbosch JW, Russo P. Additional experience with dexmedetomidine in Pediatric Patients. South Med J 2003; 96: 871-875.
22. Senzaki H, Ishido H, Iwamoto Y, et al. Sedation of hypercyanotic spells in a neonate with tetralogy of Fallot using dexmedetomidine. J Pediatr (Rio J) 2008; 84: 377-380.
21. Meretoja OA, Rautiainen P. Alfentanil and fentanyl Sedation in infants and small children during cardiac atheterization. Can J Anaesth 1990; 37: 624-628.
20. Akin A, Esmaoglu A, Guler G, Demircioglu R, Narin N, Boyaci A. Propofol and propofol-ketamine in pediatric patients undergoing cardiac catheterization. Pediatr Cardiol 2005; 26: 553-557.
19. Keller K, Beule J, Schulz A, et al. D-dimer for risk stratification in haemodynamically stable patients with acute pulmonary embolism. Adv Med Sci. 2015; 60: 204-210
18. Maestre A, Trujillo-Santos J, Visoná A, et al. RIETE Investigators. D-dimer levels and 90-day outcome in patients with acute pulmonary embolism with or without pulmonary embolism. Intern Emerg Med. cancer. Thromb Res. 2014; 133: 384-389. 2016; 11: 405-413.
17. Becattini C, Lignani A, Masotti L, et al. D-dimer for risk stratification in patients with acute pulmonary embolism. J Thromb Thrombolysis. 2012; 33: 48-57.
16. Meyer G, Vicaut E, Danays T, et al. PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014; 370: 1402-1411.
15. Rehman A, Yousaf S, Chugh A. Thrombolysis in submassive pulmonary embolism, prudent or puerile? BMJ Case Rep. 2013; 24:1-5
14. Mishkin J, Krishnan S, Mizrachi M. Thrombolytics in Acute Pulmonary Embolism Complicated by Refractory Hypoxemia. Consultant 2012; 52: 576-578.
13. Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part I: epidemiology, pathophysiology, and diagnosis. Circulation. 2003; 108:2726-2729.
12. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016; 149:315-352.
11. Erkens PM, Gandara E, Wells PS, et al. Does the Pulmonary Embolism Severity Index accurately identify low risk patients eligible for outpatient treatment? Thromb Res. 2012; 129: 710-714.
10. Righini M, Roy PM, Meyer G, et al. The Simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism. J Thromb Haemost. 2011; 9: 2115-2117.
9. Jiménez D, Aujesky D, Moores Let al. RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010; 170: 1383-1389.
8. Aujesky D, Roy PM, Verschuren F, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011; 378: 41-48.
7. Aujesky D, Perrier A, Roy PM, et al. Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med. 2007; 261: 597-604.
6. Jiménez D, Yusen RD, Otero R, et al. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. Chest. 2007; 132: 24-30.
5. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J RespirCrit Care Med. 2005; 172: 1041-1046.
4. Hellenkamp K, Kaeberich A, Schwung J, et al. Risk stratification of normotensive pulmonary embolism based on the sPESI - Does it work for all patients? Int J Cardiol. 2015; 197: 162-163.
3. Konstantinides SV, Torbicki A, Agnelli G, et al. Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014; 35: 3033-3069.
2. Riva N, Donadini MP, Ageno W. Epidemiology and pathophysiology of venous thromboembolism: similarities with atherothrombosis and the role of inflammation. Thromb Haemost 2015; 113: 1176–1183.
1. Heit JA. Epidemiology of venous thromboembolism. Nat Rev Cardiol. 2015; 12: 464-474.