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Guidelines for the risk stratification of stable patients with pulmonary embolism: The reality of practice
Acta Clinica Belgica ; 77(Supplement 2):27, 2022.
Article in English | EMBASE | ID: covidwho-2187674
ABSTRACT

Background:

Evidence-based guidelines are the best way to ensure the quality of patient care. The 2019 European Society of Cardiology (ESC) guidelines were established for the diagnosis and management of acute pulmonary embolism.

Objective:

To evaluate the adherence of clinicians to the ESC recommendations in the management of hemodynamically stable patients with pulmonary embolism. To evaluate the identification and orientation of patients at intermediate-high risk of mortality according to the guidelines (sPESI>1 and right ventricle dysfunction and positive troponin test). Material(s) and Method(s) We conducted a retrospective single-centre study on all the patients admitted into the emergency care unit (ECU) and diagnosed for pulmonary embolism from January 2021 to October 2021. Their data were collected from the patient health records of the ECU and the subsequent services where the patients were hospitalized. Hemodynamically unstable patients were excluded (Systolic blood pressure on arrival <90 mmHg, cardiac arrest or use of vasopressors). We evaluated the frequency of use of the recommended tools (PESI or sPESI) as well as the frequency of assessment of right ventricle dysfunction via imaging methods (heart ultrasound or via CT) and of laboratory biomarkers such as Troponin T (cutoff 10 pg/ml) and NT-proBNPs (cutoff 500 ng/L). For all of the selected patients, we retrospectively calculated the sPESI to assign them into three categories of early mortality risk (low, intermediate low and intermediate high) and examined whether the orientations of the patients to the intensive care unit (ICU) or other units were appropriate.

Results:

A total of 70 patients with a median age of 64 years were included. Sixteen (23%) patients were SARS-CoV2 positive. Out of the 70 patients,15 (21%) had a documented PESI or sPESI score on arrival, 51 (73%) had a troponin measured and 51 (73%) had a cardiac ultrasound performed of whom 9 (13%) had an ultrasound on arrival and 42 (60%) during their hospital stay. After calculating the sPESI on all patients based on the admission data in the ECU,16 (23%) patients were identified as being at intermediate-high risk. Amongst these 16 severely affected patients,10 had indeed benefitted from surveillance in the ICU whereas one did not benefit from surveillance and five were not transferred to the ICU based on the clinician's evaluation or the patient's desire to avoid therapeutic escalation. It appears that sPESI was more frequently calculated (33% vs 4%, p = 0,002) in patients who had certain radiological findings (bilateral embolism or embolism in a main pulmonary artery) compared to patients without radiological signs of severity.

Conclusion:

Adherence to the scores recommended by evidence-based guidelines was documented in only 23% of cases. This leaves room for improvement in the use of the PESI score and requires more systematic dosage of Troponins T and faster access to cardiac ultrasound. Our observation showed that even if radiological findings (besides signs of RV dysfunction) are not used in the ESC guidelines, some clinicians are prone to using radiological signs of severity to guide their use of the sPESI score. However, this can lead to a lack of identification and appropriate management of patients at intermediate-high risk of early mortality.
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Full text: Available Collection: Databases of international organizations Database: EMBASE Type of study: Prognostic study Language: English Journal: Acta Clinica Belgica Year: 2022 Document Type: Article

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Full text: Available Collection: Databases of international organizations Database: EMBASE Type of study: Prognostic study Language: English Journal: Acta Clinica Belgica Year: 2022 Document Type: Article