Pulmonary embolism risk stratification: where are we heading (original) (raw)
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Changes in PESI scores predict mortality in intermediate-risk patients with acute pulmonary embolism
European Respiratory Journal, 2012
Although the Pulmonary Embolism Severity Index (PESI) accurately identifies 35% of patients with acute pulmonary embolism (PE) as being low risk, some patients deemed high risk by the PESI on admission might be treated safely in the outpatient environment. This retrospective cohort study included a total of 304 consecutive patients with acute PE, classified at the time of hospital admission into PESI class III. The PESI was recalculated 48 h after admission (PESI48) and each patient reclassified into the corresponding risk category. The primary outcome of the study was all-cause mortality between day 2 and day 30 after PE diagnosis. 26 (8.5%) patients (95% CI 5.4-11.7%) died between day 2 and day 30 after PE diagnosis. Investigators reclassified 83 (27.3%) patients (95% CI 22.3-32.3%) as low risk (classes I and II) at 48 h. 30-day mortality in these patients was 1.2% (95% CI 0-3.5%) as opposed to 11.3% (95% CI 7.1-15.5%) in those who remained high risk. The net improvement in reclassification was estimated at 54% (p,0.001). In a cohort of intermediate-risk patients with acute PE, calculation of the PESI48 allows identification of those patients at very low risk of dying during the first month of follow-up.
Background and aim: Prognostic stratification of acute pulmonary embolism (PE) represents the cornerstone of modern management of this potentially life-threatening disease. In the latest years, a lot of clinical prognostic models have been validated. However, these are yet underused in clinical practice, especially in real world populations. The aim of our study was to test the prognostic ability of the Simplified Pulmonary Embolism Severity Index (sPESI) score in a real world population. Methods: Data records of 452 patients that were discharged for acute PE from 28 Internal Medicine wards of Tuscany (Italy) were retrospectively analysed. sPESI was calculated in the identical manner as the original study. Prognostic ability of sPESI score for predicting in-hospital all-cause and PE-related mortality was tested by using Areas under Receiver Operating Characteristics (ROC) curve (AUC). Results: 15.2% of patients were classified as sPESI score 0, whereas 84.8% were classified as sPESI ≥ 1. All causes of in-hospital mortality were 10.95% (5.75% PE-related) in patients with sPESI score ≥ 1 and 0% (0% PE-related) in sPESI score 0. AUC for all causes of mortality was 0.694 (95% CI: 0.650-0.736), whereas it was 0.702 (95% CI: 0.657-0.743) for PE-related mortality. Conclusion: In a real world population, sPESI is a good prognosticator for all causes of in-hospital and PE-related mortality and its use should be encouraged.
Egyptian Journal of Bronchology, 2019
Background Acute pulmonary embolism (PE) is a potentially fatal disease. Prognostic assessment is needed for proper management. Several prognostic models have been proposed. Aim The aim was to validate the original pulmonary embolism severity index (o-PESI) with its simplified version (s-PESI) and modified version (m-PESI) as predictors of in-hospital mortality and homeostatic morbidities (nonlethal repeated venous thromboembolism, and/or nonlethal serious hemorrhage) in patients with PE. Patients and methods Patients proved to have acute PE admitted to Menoufia and Cairo University Hospitals between March 2017 and March 2019 were included in the study. The o-PESI, s-PESI, and m-PESI were calculated for each patient. In-hospital mortality, homeostatic morbidities, and major adverse events (mortality and homeostatic morbidities) were registered. Results One hundred and two patients were recruited. Inhospital mortality rate was 13.7%, morbidity rate was 21.6%, whereas major adverse events rate was 31%. The s-PESI classified 31.4% of patients as low risk, and none of them had in-hospital mortality. The frequencies of major adverse events in the low-risk groups were 31.2, 9.1, and 75% for o-PESI, s-PESI, and m-PESI, respectively. Difference between adverse events and non-adverse events groups was significant when s-PESI was applied (P=0.008). The s-PESI had the highest sensitivity and negative predictive value in detecting mortality, morbidity, and major adverse events compared with o-PESI and m-PESI. The area under the curve for s-PESI was significantly above the other two indices (area under the curve=0.78, P=0.04). Conclusion In addition to its easy application, the s-PESI has a preferably superior prognostic accuracy than o-PESI and m-PESI in prognostication of low-risk patients with acute PE.
International Journal of Research in Medical Sciences, 2015
Background: Prognostic stratification is of utmost importance for management of acute Pulmonary Embolism (PE) in clinical practice. Many prognostic models have been proposed, but which is the best prognosticator in real life remains unclear. The aim of our study was to compare and combine the predictive values of the hemodynamics/biomarkers based prognostic model proposed by European Society of Cardiology (ESC) in 2008 and simplified PESI score (sPESI). Methods: Data records of 452 patients discharged for acute PE from Internal Medicine wards of Tuscany (Italy) were analysed. The ESC model and sPESI were retrospectively calculated and compared by using Areas under Receiver Operating Characteristics (ROC) Curves (AUCs) and finally the combination of the two models was tested in hemodinamically stable patients. All cause and PE-related in-hospital mortality and fatal or major bleedings were the analyzed endpoints Results: All cause in-hospital mortality was 25% (16.6% PE related) in high risk, 8.7% (4.7%) in intermediate risk and 3.8% (1.2%) in low risk patients according to ESC model. All cause in-hospital mortality was 10.95% (5.75% PE related) in patients with sPESI score ≥1 and 0% (0%) in sPESI score 0. Predictive performance of sPESI was not significantly different compared with 2008 ESC model both for all cause (AUC sPESI 0.711, 95% CI: 0.661-0.758 versus ESC 0.619, 95% CI: 0.567-0.670, difference between AUCs 0.0916, p=0.084) and for PE-related mortality (AUC sPESI 0.764, 95% CI: 0.717-0.808 versus ESC 0.650, 95% CI: 0.598-0.700, difference between AUCs 0.114, p=0.11). Fatal or major bleedings occurred in 4.30% of high risk, 1.60% of intermediate risk and 2.50% of low risk patients according to 2008 ESC model, whereas these occurred in 1.80% of high risk and 1.45% of low risk patients according to sPESI, respectively. Predictive performance for fatal or major bleeding between two models was not significantly different (AUC sPESI 0.658, 95% CI: 0.606-0.707 versus ESC 0.512, 95% CI: 0.459-0.565, difference between AUCs 0.145, p=0.34). In hemodynamically stable patients, the combined endpoint in-hospital PE-related mortality and/or fatal or major bleeding (adverse events) occurred in 0% of patients with low risk ESC model and sPESI score 0, whilst it occurred in 5.5% of patients with low-risk ESC model but sPESI ≥1. In intermediate risk patients according to ESC model, adverse events occurred in 3.6% of patients with sPESI score 0 and 6.65% of patients with sPESI score ≥1. Conclusions: In real world, predictive performance of sPESI and the hemodynamic/biomarkers-based ESC model as prognosticator of in-hospital mortality and bleedings is similar. Combination of sPESI 0 with low risk ESC model may identify patients with very low risk of adverse events and candidate for early hospital discharge or home treatment.
Pakistan Journal of Medical Sciences, 1969
INTRODUCTION The stratification of acute pulmonary embolism (PE) using the simplified pulmonary embolism severity index (sPESI) and shock index (SI) does not require any prognostic tools such as biomarkers or echocardiography. OBJeCTIVes We compared the ability of the sPESI and SI to predict 30-day and 3-year mortality following PE. PATIeNTs AND MeTHODs Prognostic models based on the sPESI and SI were used to predict the overall 30-day (short-term) and 3-year (long-term) mortality in a cohort of 194 patients with confirmed PE. ResULTs Overall, the mortality rate in this cohort was 9.2% in the first month and 29.9% at 3 years. The sPESI categorized fewer patients as low risk (41.7%; 81 of 194 patients) when compared with the SI lower than 1 (74.7%; 145 of 194 patients). Importantly, patients classified as low risk in the sPESI had no 30-day mortality compared with 2.1% of patients (3 of 145) classified as low-risk based on the SI. The 3-year mortality rate in low-risk patients according to the sPESI was lower than that in low-risk patients identified based on the SI (4.9% vs. 20.7%; P <0.0001). While a multivariate Cox analysis showed that both the SI and sPESI were independent prognostic variables for 3-year mortality, it showed that only the SI was an independent prognostic variable for 30-day mortality. CONCLUsIONs Both prognostic models allow to stratify the risk of short-and long-term mortality in patients with PE, but the sPESI was better than SI at classifying low-risk patients.
Is the Pulmonary Embolism Severity Index Being Routinely Used in Clinical Practice
Background. The Pulmonary Embolism Severity Index (PESI) score can risk-stratify patients with PE but its widespread use is uncertain. With the PESI, we compared length of hospital stay between low, moderate, and high risk PE patients and determined the number of low risk PE patients who were discharged early. Methods. PE patients admitted to St. Joseph Mercy Oakland Hospital from January 2005 to August 2010 were screened. PESI score stratified acute PE patients into low (<85), moderate (86–105), and high (>105) risk categories and their length of hospital stay was compared. Patients with low risk PE discharged early (≤3 days) were calculated. Results. Among 315 PE patients, 51.7% were at low risk. No significant difference in hospital stay between low (7.11 ± 3 d) and moderate (6.88 ± 2.9 d) risk, p > 0.05, as well as low and high risk (7.28 ± 3.0 d), p > 0.05, was found. 9% of low risk patients were discharged ≤ 3 days. Conclusions. There was no significant difference in length of hospital stay between low and high risk groups and only a small number of low risk patients were discharged from the hospital early suggesting that risk tools like PESI may not have a widespread use.
Chest, 2007
To assess the performance of two prognostic models in predicting short-term mortality in patients with pulmonary embolism (PE). Subjects and methods: We compared the test characteristics of two prognostic models for predicting 30-day outcomes (mortality, thromboembolic recurrences, and major bleeding) in a cohort of 599 patients with objectively confirmed PE. Patients were stratified into the PE severity index (PESI) risk classes I-V and the Geneva low-risk and high-risk strata. We compared the discriminatory power of both prognostic models. Results: The PESI classified fewer patients as low risk (strata I and II) [36%; 216 of 599 patients; 95% confidence interval (CI), 32 to 40%] compared to the Geneva prediction rule (84%; 502 of 599 patients; 95% CI, 81 to 87%) [p < 0.0001]. Using either prediction rule, the low-risk groups showed statistically relevant 30-day mortality difference (PESI, 0.9%; 95% CI, 0.3 to 2.2; vs Geneva, 5.6%; 95% CI, 3.6 to 7.6) [p < 0.0001], although nonfatal recurrent venous thromboembolism or major bleeding rates were statistically similar (PESI, 2.8%; 95% CI, 0.6 to 5.0%; vs Geneva, 4.2%; 95% CI, 2.4 to 5.9%). The area under the receiver operating characteristic curve was higher for the PESI (0.76; 95% CI, 0.69 to 0.83) than for the Geneva score (0.61; 95% CI, 0.51 to 0.71) [p ؍ 0.002]. Conclusions: The PESI quantified the prognosis of patients with PE better than the Geneva score. This study demonstrated that PESI can select patients with very low adverse event rates during the initial days of acute PE therapy and assist in selecting patients for treatment in the outpatient setting.