Acil Serviste Pulmoner Emboli Tanısı Alan Hastalarda Plazma Laktatının Prognostik Rolü

Öz

Amaç: Pulmoner emboli (PE) en sık görülen üçüncü akut kardiyovasküler hastalıktır. Acil servisde 1 Ocak 2021 ile 1 Temmuz 2023 tarihleri arasında PE tanısı alan hastaların retrospektif analizi yapıldı. 2019 Avrupa Kardiyoloji Cemiyeti (ESC) algoritmasına venöz laktat eklenmesi risk sınıflandırmasını iyileştirebilmekle birlikte, çalışmamızda da yüksek laktat seviyesi ile ilişkili sağ ventrikül fonksiyon bozukluğu kombinasyonu ile acil serviste erken tedavi kararları ve mortalite tahminlerinde yol göstermede katkıda bulunması öngörülmektedir. Gereç ve Yöntem: Retrospektif olarak, hastaların demografik verileri, vital bulguları, ek hastalıkların varlığı ve plazma laktat düzeyleri ile sonlanımları analiz edildi. 30 günlük mortaliteyi öngörmede ‘Pulmonary Embolism Severity Index’ (PESI), sağ kalp yetmezliği ve plazma laktat seviyeleri istatistiksel olarak analiz edildi. Bulgular: Çalışmada PE tanısı alan 104 hastanın kategorik parametreleri; %52,9’u (n=55) kadın, %48,1’i (n=50) sigara kullanıyor ve %91,3’ünde (n=95) de ek hastalıkları var idi. %19,2’sinde (n=20) sağ ventrikül yetmezliği saptanmış olup, mortalitesi de %24,96 idi. Sağ ventrikül yetmezliği olan hastaların ortanca plazma laktat düzeyleri (2,25 mmol/L), sağ ventrikül yetmezliği gelişmeyenlere (1,7 mmol/L) kıyasla anlamlı yüksek idi (p=0,01). PESI sınıflamasına göre plazma laktat düzeylerinin karşılaştırılmasında Sınıf I (1,3 mmol/L) – II (1,9 mmol/L), Sınıf I (1,3 mmol/L) – IV ( 2,4 mmol/L), Sınıf I (1,3 mmol/L) – Sınıf V (1,9 mmol/L) ve Sınıf III (1,6 mmol/L) - IV (2,4 mmol/L) arasında istatistiksel olarak anlamlı fark mevcuttu (p<0,05). Sonuç: Çalışmada yüksek laktat seviyesi ile sağ ventrikül fonksiyon bozukluğu arasında korelasyon bulunmuştur. Sonuç olarak; acil serviste plazma laktat düzeyleri PE tanısı alan hastalarda erken tedavi kararlarında, prognozda ve mortalite tahminlerinde yol göstermede katkıda bulunacağı düşünülmektedir.

Anahtar Kelimeler

• Acil servis
• Pulmoner emboli
• Laktat
• Prognoz
• PESI

The Prognostic Role of Plasma Lactate in Patients Diagnosed with Pulmonary Embolism in the Emergency Department

Öz

Objective: Pulmonary embolism (PE) is the third most common acute cardiovascular disease. This retrospective study was analyzed of the patients diagnosed with PE, between January 1, 2021 and July 1, 2023, in the emergency department (ED). Although the addition of venous lactate to the 2019 European Society of Cardiology (ESC) algorithm may improve risk classification, it is anticipated that our study will contribute to guiding early treatment decisions and mortality predictions in the ED with the combination of right ventricular dysfunction associated with high lactate levels. Material and Methods: Demographic data, vital signs, presence of additional diseases, plasma lactate levels and outcomes of the patients were analyzed retrospectively. ‘Pulmonary Embolism Severity Index’ (PESI), right heart failure, and plasma lactate levels were statistically analyzed to predict 30-day mortality. Results: Categorical parameters of 104 patients diagnosed with PE in the study; 52.9% (n=55) were women, 48.1% (n=50) were smokers, and 91.3% (n=95) had comorbidities. Right ventricular failure was detected in 19.2% (n=20) and the mortality was 24.96%. When comparing lactate levels according to the PESI classification, there was a statistically significant difference between Class I (1.3 mmol/L) – II (1.9 mmol/L), Class I (1.3 mmol/L) – IV ( 2.4 mmol/L), Class I (1.3 mmol/L) – Class V (1.9 mmol/L) and, Class III (1.6 mmol/L) - IV (2.4 mmol/L) (p<0.05). Conclusion: The study found a correlation between high plasma lactate level and right ventricular dysfunction. In conclusion; It is thought that plasma lactate levels in the emergency department will contribute to guiding early treatment decisions, prognosis and mortality predictions in patients diagnosed with PE.

Anahtar Kelimeler

• Pulmonary embolism
• Emergency department
• PESI
• Lactate
• Prognosis

Kaynakça

1. Raskob GE, Angchaisuksiri P, Blanco AN, Buller H, Gallus A, Hunt BJ, et al. Thrombosis: a major contributor to global disease burden. Arterioscler Thromb Vasc Biol. 2014;34(11):2363–2371.
2. İpekci A. Pulmoner Emboli 2019, Anka Tıp Dergisi. 2019;1(1):51-63.
3. Ammar H, Ohri C, Hajouli S, Kulkarni S, Tefera E, Fouda R, et al. Prevalence and Predictors of Pulmonary Embolism in Hospitalized Patients with Syncope. South Med J. 2019 Aug;112(8):421-427. DOI: 10.14423/SMJ.0000000000001009.
4. Vanni S, Jiménez D, Nazerian P, Morello F, Parisi M, Daghini E, et al. Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate. Thorax. 2015 Apr;70(4):333-341. DOI: 10.1136/thoraxjnl-2014-206300.
5. Becattini C, Agnelli G, Lankeit M, Masotti L, Pruszczyk P, Casazza F, et al. Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model. Eur Respir J. 2016 Sep;48(3):780-786. DOI: 10.1183/13993003.00024-2016.
6. Aujesky D, Perrier A, Roy PM, Stone RA, Cornuz J, Meyer G, et al. Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med. 2007 Jun;261(6):597-604. DOI: 10.1111/j.1365-2796.2007.01785.x.
7. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020 Jan 21;41(4):543-603. DOI: 10.1093/eurheartj/ehz405.
8. Ma X, Li J, Zhou Q and Wang J. Serum lactate and the mortality of critically ill patients in the emergency department: A retrospective study. Exp Ther Med. 2023; 26: 371. DOI:10.3892/etm.2023.12070.

9. Seker YC, Bozan O, Sam E, Topacoglu H, Kalkan A. The role of the serum lactate level at the first admission to the emergency department in predicting mortality. Am J Emerg Med. 2021;45:495–500. DOI: 10.1016/j.ajem.2020.09.088.
10. Özçete E, Uz İ, Altuntaş S, Karan D, Karbek Akarca F. The Effect of Lactate and Lactate Clearance on Mortality in Patients with Acute Pulmonary Embolism in Emergency Department. Anatolian J Emerg Med. 2022; 5(2): 68-73.
11. Ebner M, Pagel CF, Sentler C, Harjola VP, Bueno H, Lerchbaumer MH, et al. Venous lactate improves the prediction of in-hospital adverse outcomes in normotensive pulmonary embolism. Eur J Intern Med. 2021 Apr;86:25-31. DOI: 10.1016/j.ejim.2021.01.021.
12. Harjola VP, Mebazaa A, Čelutkienė J, Bettex D, Bueno H, Chioncel O, et al. Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology. Eur J Heart Fail. 2016 Mar;18(3):226-241. DOI: 10.1002/ejhf.478.
13. Elf JE, Jögi J, Bajc M. Home treatment of patients with small to medium sized acute pulmonary embolism. J Thromb Thrombolysis. 2015;39(2):166-172.
14. Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011;378(9785):41-48. DOI: 10.1016/S0140-6736(11)60824-6.
15. Kraut JA, Madias NE. Lactic acidosis. N. Engl. J. Med. 2014;371(24):2309–2319. DOI: 10.1056/NEJMra1309483.
16. Vanni S, Viviani G, Baioni M, Pepe G, Nazerian P, Socci F, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med. 2013 Mar;61(3):330-338. DOI: 10.1016/j.annemergmed.2012.10.022.
17. Ząbczyk M, Natorska J, Janion-Sadowska A, Malinowski KP, Janion M, Undas A. Elevated Lactate Levels in Acute Pulmonary Embolism Are Associated with Prothrombotic Fibrin Clot Properties: Contribution of NETs Formation. J Clin Med. 2020;9(4):953. DOI:10.3390/jcm9040953.
18. Vanni S, Socci F, Pepe G, Nazerian P, Viviani G, Baioni M, et al. High plasma lactate levels are associated with increased risk of in-hospital mortality in patients with pulmonary embolism. Acad Emerg Med. 2011;18(8):830-835. DOI: 10.1111/j.1553-2712.2011.01128.x.
19. Galić K, Pravdić D, Prskalo Z, Kukulj S, Starčević B, Vukojević M. Prognostic value of lactates in relation to gas analysis and acid-base status in patients with pulmonary embolism. Croatian Medical Journal. 2018;59(4):149-55.
20. Giri J, Sista AK, Weinberg I, Kearon C, Kumbhani DJ, Desai ND, et al. Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association. Circulation. 2019;140(20):e774-e801. DOI: 10.1161/CIR.0000000000000707.
21. Meneveau N. Venous lactate: The new “magic marker” for stratification in intermediate-risk pulmonary embolism?. Eur J Intern Med. 2021;86:32-33. DOI:10.1016/j.ejim.2021.03.004.