Embolie pulmonaire: stratification du risque

Embolie pulmonaire: stratification du risque Olivier Sanchez Université Paris Descartes Service de Pneumologie et Soins Intensifs, HEGP, Paris MATIS...
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Embolie pulmonaire: stratification du risque Olivier Sanchez Université Paris Descartes Service de Pneumologie et Soins Intensifs, HEGP, Paris

MATISSE Study 2213 patients avec EP randomisés fondaparinux / HNF IVSE au moins 5j puis relais AVK

Evènement

Fondaparinux

Héparine

(n=1103)

(n=1110)

1.3% 3.8%

1.7% 5.0%

1.3% 2.0%

1.1% 2.4%

0.8% 5.2%

1.1% 4.4%

Récidive ttt initial à 3 mois

Hémorragie majeure ttt initial à 3 mois

Décès ttt initial à 3 mois

N Engl J Med 2003;349:1695-1702

Mortalité de l’EP dans les registres n

Mortalité précoce

Mortalité tardive

Ferrari 1997

387

6,2*

ND

Goldhaber 1999

2393

9,2**

15,3§

Murin 2002

21.625

6,0*

14,7£ §

Stein 1999

819

10,8**

18,6

Arcellus 2003

1609

ND

14,8§

*: hospitalière; **: 14 jours; §: 3mois; £: 6 mois

↑ Post-charge VD Dilatation VD ↑Pré-charge VD ↑ FC, Effet Starling

Interdépendance VD/ VG

Dysfonction VD

Contraintes péricardiques

Syst et diast

↓FEVD ↓Pré-charge VG

Ischémie VD

↓Débit coronaire HypoPA

↑ Post-charge VD Echo cœur

Dilatation VD ↑Pré-charge VD

BNP

↑ FC, Effet Starling Troponine Interdépendance VD/ VG

Dysfonction VD

Contraintes péricardiques

Syst et diast

↓FEVD ↓Pré-charge VG

Ischémie VD

↓Débit coronaire HypoPA

Mortalité et tolérance hémodynamique International Cooperative Pulmonary Embolism Registry (ICOPER)

•  2454 patients consécutifs (52 centres) •  Mortalité à J15: 9,6 % (219) •  Mortalité à 3 mois •  mortalité globale: 17,4 % (426) •  Hémodynamique stable: 15,1% (317 / 2093) •  Hémodynamique instable: 58,3 % (56 / 96) Goldhaber et al. Lancet 1999;353:1386-89

Mortalité et terrain International Cooperative Pulmonary Embolism Registry (ICOPER)

•  2454 patients consécutifs (52 centres) •  Facteurs de risque de mortalité à 3 mois: •  Age > 70 ans (hazard ratio 1,6 [IC95% 1,1-2,3]) •  Cancer (2,3 [IC95% 1,5-3,5]) •  I Cardiaque (2,4 [IC95% 1,5-3,7]) •  BPCO (1,8 [IC95% 1,2-2,7]) Goldhaber et al. Lancet 1999;353:1386-89

Score de gravité clinique de l’EP: PESI

Aujesky et al. AJRCCM 2005; 172: 1041-6; Jimenez et al. Arch Intern Med 2010;170:1383-9

Simplified PESI

Jimenez D. et al. Arch Intern Med 2010; 170: 1383-9

Mortalité à J30 selon le score PESI

Jimenez et al. Arch Intern Med 2010;170:1383-9

Death or major complication PESI class I-II •  Death or recurrent PE: 1% (NPV: 95 (90-98) Spirk D et al. Thromb Haemost 2011; 106: 978-84

•  Death, recurrent PE, major bleeding: 1.8% (NPV: 98.2 (96.1-100) Lankeit M. et al Chest 2011

•  Death, recurrent PE, shock: 2.1% (NPV: 98%) Sanchez O. et al Eur Respir J 2013

Echocardiographie pour le diagnostic de cœur pulmonaire aigu •  Diamètre télédiastolique VD > 30 mm •  VD / VG > 1 •  Hypokinésie de la paroi libre du VD •  Septum interventriculaire paradoxal •  IT •  Absence de collapsus inspiratoire VCI

Mortalité hospitalière et échocardiographie Malades cliniquement stables (5 études)

2.53 (1.17-5.50)

O Sanchez et al Eur Heart J 2008

Angioscanner spiralé et mortalité

Van der Meer Radiology 2005

This article has supplementary material available from www.erj.ersjournals.com

| | Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis

Received: Aug 23 2013

Accepted after revision: Dec 27 2013

First published online: March 6 2014

Conflict of interest: Disclosures can be found alongside the online version of this article at www.erj.ersjournals.com Copyright !ERS 2014

1678

Eur Respir J 2014; 43: 1678–1690 | DOI: 10.1183/09031936.00147813

PULMONARY VASCULAR DISEASES | C. BECATTINI ET AL

Cecilia Becattini, Giancarlo Agnelli, Federico Germini and Maria Cristina Vedovati

EP choquée ou non

First author [ref.] Weight % OR (95% CI) CT-RVC +ve CT-RVD -ve OR (95% CI) Affiliation: M–H, Fixed of Perugia, Perugia,M–H, Fixed Events Total Events Total Internal and Cardiovascular Medicine and Stroke Unit, University Italy. Transverse 0 18 0.4 16.35 (0.89–300.40) 9 30 BAZEEDCorrespondence: [24] C. [11] Becattini, 21 Internal Medicine and Unit, University of Perugia, Via G Dottori 1, 4 154 5.1 2.79Stroke (0.94–8.28) 303and Cardiovascular BECATTINI 06129, Perugia, Italy. 22 521 7.0 3.98 (2.04–7.76) 17 114 FURLAN [28] E-mail: [email protected] 13 315 16.2 1.14 (0.58–2.27) 25 533 JIMÉNEZ [32] 5 112 5.3 2.41 (0.85–6.85) 15 148 KANG [34] ABSTRACT The aim of this study was to evaluate whether right ventricle dilation at computed 0 36 0.7 23 164 12.12 (0.72–204.35) [36] KUMAMURU tomography (CT) angiography can be used to assess the risk of death in patients with acute pulmonary 19 222 21.9 452 2.23 (1.31–3.78) LU [39]embolism. 78 6 searched 60 8 EMBASE 48 1.802013. (0.58–5.60) OZSU [44] Medline and were up 4.6 to April 30, Studies reporting on the association between 2 79 2.0 2 78 1.01 (0.14–7.38) STEIN [49] right ventricle dilation (right-to-left ventricle diameter) or dysfunction (inter-ventricular septal bowing) at 3 19 4.3 20 106 (0.33–4.67) VENKATESH CT [52] angiography and death at 30 days, as well as at 31.24 months in patients with acute pulmonary embolism, 4 269 3.5 5 201 1.69 (0.45–6.38) ZONDAG [53]

were included in a systematic review and meta-analysis.

1805 was associated 71.2 2177 2.25 (1.69–3.00) Subtotal CT-detected (95% CI) right ventricle dilation with an increased 30 day-mortality in all-comers with 78 223 Total events pulmonary embolism (OR 2.08 (95% CI 1.63–2.66); p,0.00001) and in haemodynamically stable patients 2 Heterogeneity: Chi-squared=11.57, df=10 (p=0.31); I =14% (OR effect: 1.64 (95% 1.06–2.52); p50.03), as well as with death due to pulmonary embolism (OR 7.35 (95% Test for overall Z=5.53CI (p