INTRODUCTION: Pulmonary embolism still represents a challenging clinical scenario in the emergency room setting, both diagnostically since there is a wide spectrum of clinical presentation, both logistically in defining the best ward and therapeutic strategy for PE magament. MATERIALS AND METHODS: With the aim to try to implement the indications on critical care unit admission and use of reperfusion strategies reserved for high-risk and intermediate-high risk PE patients, we analysed all patients that in the biennium 2021-2022 recevied a diagnosis of acute pulmonary embolism in the emergency room, 298 in total. RESULTS: 267 were hospitalized, and among those that received admission, 45 were admitted in a high-intensity ward. Between the hospitalized patients who received therapy, 7 underwent EKOS procedure and 1 systemic thrombolysis, necessitating so a critical care unit admission (CCU). 30 days mortality was 11,4%, with 6 patients dying in the ER near diagnosis time. Considering D-dimer and hsTnI, two laboratory parameters that were asked respectively in 80,9% and 86,2% of cases, and signs of right ventricular dysfunction at trans-thoracic echocardiography we hypothesized a score which could predict admission in a critical care unit, use of reperfusion strategies like EKOS, and finally short-term prognosis. The cut-off used for D-dimer and hsTnI were 10405 ng/L and 236 ng/L both extrapolated by ROC analysis in association with CCU admission. The derived score, which we defined TED score, considers a score point=2 for signs of right ventricular dysfunction at TTE and a troponin value above cut-off, while it considers score=1 for a D-dimer value above cut-off. By adding the points obtained with the rules abovementioned a minimum of 1 and maximum of 5 points can be obtained. CONCLUSION: A TED score > 3 was able to predict admission in a CCU with a sensitivity of 70,0% and specificity of 85,7%. However, we weren’t able to demonstrate an association with short-term mortality, both when considering the single parameters of TED score, both when considered in conjunction.
INTRODUZIONE: L’ embolia polmonare rappresenta ancora uno scenario clinico di difficile gestione nel setting del pronto soccorso, sia dal punto di vista diagnostico visto l’ampio spettro di rappresentazione clinica, sia dal punto di vista logistico nella scelta del reparto di ricovero e della strategia terapeutica più adeguati. MATERIALI E METODI: Con l’obiettivo di cercare di implementare le indicazioni all’ammissione in un reparto di alta-intensità di cura e all’’utilizzo di procedure riservate ai pazienti con embolia polmonare a rischio elevato ed intermedio-alto, abbiamo analizzato tutti i pazienti che nel biennio 2021-2022 hanno ricevuto una diagnosi di embolia polmonare in pronto soccorso, 298 in totale. RISULTATI: 267 di questi sono stati ricoverati, e tra quelli che hanno ricevuto ricovero, 45 sono stati accolti in un reparto ad alta-intensità. Tra i pazienti ospedalizzati che hanno ricevuto terapia, 7 sono stati sottoposti a procedura EKOS ed 1 a trombolisi sistemica richiedendo dunque l’ammissione in un reparto ad alta-intensità. La mortalità nei primi 30 giorni è risultata essere dell’11,4%, con 6 pazienti deceduti in pronto soccorso a ridosso della diagnosi. Prendendo in considerazione il D-dimero e l’hsTnI, parametri di laboratorio che abbiamo riscontrato essere richiesti rispettivamente nel 80,9% e nel 86,2% dei casi, e segni di disfunzione ventricolare destra acuta all’ ecografia trans-toracica abbiamo ipotizzato uno score che potesse predire l’ammissione in una terapia intensiva, l’utilizzo dell’EKOS come metodica terapeutica, ed infine la prognosi a breve termine. I cut-off utilizzati per D-dimero e hsTnI sono stati rispettivamente 10405 ng/L e 236 ng/L estrapolati entrambi dalla curva ROC in associazione all’ammissione in una critical-care unit (CCU). Lo score così ottenuto, che abbiamo definito TED score, considera come punteggio =2 rispettivamente la presenza di segni di disfunzione destra acuta all’ETT e un valore di troponina sopra al cut-off stabilito, mentre considera punteggio =1 un valore di D-dimero sopra al cut-off riportato. Sommando il punteggio ottenuto dai parametri sopracitati si ottiene un minimo di 1 e massimo di 5. CONCLUSIONI: Un TED score > 3 si è dimostrato in grado di predire la necessità di cure intensive con una sensibilità del 70,0% e specificità dell’85,7%. Tuttavia, non siamo stati in grado di dimostrare un’associazione con i decessi a breve termine, sia prendendo in considerazione i singoli parametri del TED score, sia quando considerati in congiunzione.
THE PROGNOSTIC ROLE OF D-DIMER IN PULMONARY EMBOLISM PATIENTS IN THE EMERGENCY DEPARTMENT
MONTI, DEBORA
2022/2023
Abstract
INTRODUCTION: Pulmonary embolism still represents a challenging clinical scenario in the emergency room setting, both diagnostically since there is a wide spectrum of clinical presentation, both logistically in defining the best ward and therapeutic strategy for PE magament. MATERIALS AND METHODS: With the aim to try to implement the indications on critical care unit admission and use of reperfusion strategies reserved for high-risk and intermediate-high risk PE patients, we analysed all patients that in the biennium 2021-2022 recevied a diagnosis of acute pulmonary embolism in the emergency room, 298 in total. RESULTS: 267 were hospitalized, and among those that received admission, 45 were admitted in a high-intensity ward. Between the hospitalized patients who received therapy, 7 underwent EKOS procedure and 1 systemic thrombolysis, necessitating so a critical care unit admission (CCU). 30 days mortality was 11,4%, with 6 patients dying in the ER near diagnosis time. Considering D-dimer and hsTnI, two laboratory parameters that were asked respectively in 80,9% and 86,2% of cases, and signs of right ventricular dysfunction at trans-thoracic echocardiography we hypothesized a score which could predict admission in a critical care unit, use of reperfusion strategies like EKOS, and finally short-term prognosis. The cut-off used for D-dimer and hsTnI were 10405 ng/L and 236 ng/L both extrapolated by ROC analysis in association with CCU admission. The derived score, which we defined TED score, considers a score point=2 for signs of right ventricular dysfunction at TTE and a troponin value above cut-off, while it considers score=1 for a D-dimer value above cut-off. By adding the points obtained with the rules abovementioned a minimum of 1 and maximum of 5 points can be obtained. CONCLUSION: A TED score > 3 was able to predict admission in a CCU with a sensitivity of 70,0% and specificity of 85,7%. However, we weren’t able to demonstrate an association with short-term mortality, both when considering the single parameters of TED score, both when considered in conjunction.È consentito all'utente scaricare e condividere i documenti disponibili a testo pieno in UNITESI UNIPV nel rispetto della licenza Creative Commons del tipo CC BY NC ND.
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https://hdl.handle.net/20.500.14239/15963