P6463Prognostic value of respiratory index (RI) in hemodinamically stable patients with acute pulmonary embolism: the RI-MODEL study

Abstract Background The accuracy of the 2014 ESC model to predict 30-day mortality in hemodynamically stable patients with acute pulmonary embolism (PE) is relatively limited. Purpose The aims of this study in hemodynamically stable patients with acute PE were i) to evaluate the prognostic value of a novel respiratory index (RI) (oxygen saturation in air to respiratory rate ratio) and ii) to assess the accuracy of the RI-model (simplified Pulmonary Embolism Severity Index [sPESI] + RI), both in predicting 30-day mortality. Methods A collaborative database of hemodynamically stable patients with PE was divided into two cohorts (derivation and validation) with equal numbers of patients, based on a temporal criterion. Study outcome was 30-day all-cause-death. Discrimination and calibration were assessed in the derivation and validation cohorts by the c-statistics and by the Hosmer-Lemeshow test, respectively. Results 30-day all-cause-death occurred in 7.5% of the 319 patients in the derivation cohort (mean age 72 years, females 53%). The RI was an independent predictor of 30-day mortality (p=0.004). A RI ≤3.8 was associated with an increased death rate compared to higher RI values (15.4% vs 5.0%, OR 3.4, 95% CI 1.5–8.1). When the RI≤3.8 was integrated in the sPESI, the novel RI-model showed a good discriminatory power (c-statistics 0.703, 95% CI 0.603–0.803). In the 319 patients of the validation cohort (30-day mortality 6.9%, mean age 71 years, females 55%) the discriminatory power of the RI-model was confirmed (c-statistics 0.838, 95% CI 0.768–0.907). The RI-model and the 2014 ESC model had a c-statistics of 0.772 (95% CI 0.709–0.834) and of 0.687 (95% CI 0.620–0.753) in the overall population, respectively. Conclusion In this study, the RI independently predicted 30-day mortality in hemodynamically stable patients with acute PE. A clinical model including RI showed a better discriminatory value than 2014 ESC model and could be used for risk stratification in these patients.

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Prognostic value of respiratory index in haemodynamically stable patients with acute pulmonary embolism: The Respiratory Index model study

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872620913849 ◽

2020 ◽

Vol 9 (4) ◽

pp. 286-292

Author(s):

Maria Cristina Vedovati ◽

Ludovica Anna Cimini ◽

Lucia Pierpaoli ◽

Simone Vanni ◽

Marilena Cotugno ◽

...

Keyword(s):

Pulmonary Embolism ◽

Confidence Interval ◽

Odds Ratio ◽

Prognostic Value ◽

Acute Pulmonary Embolism ◽

Severity Index ◽

Derivation Cohort ◽

Index Model ◽

C Statistic ◽

Respiratory Index

Background: Current strategies for prognostic stratification in haemodynamically stable patients with acute pulmonary embolism require improvement. The aims of this study in haemodynamically stable patients with acute pulmonary embolism were (a) to evaluate the prognostic value of a novel respiratory index (oxygen saturation in air to respiratory rate ratio) and (b) to derive a risk model which includes the respiratory index and evaluate its value in predicting 30-day mortality. Methods: Prospective cohorts of haemodynamically stable patients with acute pulmonary embolism were merged to a collaborative database that served to create two subsequent derivation and validation cohorts based on a temporal criterion. The study outcome was 30-day all-cause death. Results: Thirty-day all-cause death occurred in 7.5% and in 6.9% of patients in the derivation and validation cohorts (each composed of 319 patients). In the derivation cohort, the respiratory index (odds ratio 0.66, 95% confidence interval 0.48–0.90) and simplified Pulmonary Embolism Severity Index (odds ratio 9.16, 95% confidence interval 1.22–68.89) were predictors of 30-day mortality. The cut-off value of the respiratory index ⩽3.8 was identified to best predict 30-day all-cause death (15.4% vs 5.0%, odds ratio 2.94, 95% confidence interval 1.22–7.11). The respiratory index ⩽3.8 was combined with the simplified Pulmonary Embolism Severity Index to create the Respiratory Index model that showed a good discriminatory power in the derivation (c-statistic 0.703, 95% confidence interval 0.60–0.80) and in the validation cohort (c-statistic 0.838, 95% confidence interval 0.768–0.907). Conclusion: In hemodynamically stable patients with acute pulmonary embolism, the respiratory index was an independent predictor of 30-day all-cause death. The Respiratory Index model which includes the simplified Pulmonary Embolism Severity Index and the respiratory index, provides a good risk stratification of haemodynamically stable patients with acute pulmonary embolism.

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Developing a scoring tool to estimate the risk of deterioration for normotensive patients with acute pulmonary embolism on admission

Respiratory Research ◽

10.1186/s12931-020-01602-x ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Yizhuo Gao ◽

Chao Ji ◽

Hongyu Zhao ◽

Jun Han ◽

Haitao Shen ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Clinical Laboratory ◽

Systolic Pressure ◽

Adverse Outcomes ◽

Web Based ◽

Derivation Cohort ◽

Risk Scoring ◽

Scoring Tool ◽

Acute Pe

Abstract Background It is important to identify deterioration in normotensive patients with acute pulmonary embolism (PE). This study aimed to develop a tool for predicting deterioration among normotensive patients with acute PE on admission. Methods Clinical, laboratory, and computed tomography parameters were retrospectively collected for normotensive patients with acute PE who were treated at a Chinese center from January 2011 to May 2020 on admission into the hospital. The endpoint of the deterioration was any adverse outcome within 30 days. Eligible patients were randomized 2:1 to derivation and validation cohorts, and a nomogram was developed and validated by the aforementioned cohorts, respectively. The areas under the curves (AUCs) with 95% confidence intervals (CIs) were calculated. A risk-scoring tool for predicting deterioration was applied as a web-based calculator. Results The 845 eligible patients (420 men, 425 women) had an average age of 60.05 ± 15.43 years. Adverse outcomes were identified for 81 patients (9.6%). The nomogram for adverse outcomes included heart rate, systolic pressure, N-terminal-pro brain natriuretic peptide, and ventricle/atrial diameter ratios at 4-chamber view, which provided AUC values of 0.925 in the derivation cohort (95% CI 0.900–0.946, p < 0.001) and 0.900 in the validation cohort (95% CI 0.883–0.948, p < 0.001). A risk-scoring tool was published as a web-based calculator (https://gaoyzcmu.shinyapps.io/APE9AD/). Conclusions We developed a web-based scoring tool that may help predict deterioration in normotensive patients with acute PE.

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A New Model for Risk Stratification of Patients With Acute Pulmonary Embolism

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029618808922 ◽

2018 ◽

Vol 24 (9_suppl) ◽

pp. 277S-284S ◽

Cited By ~ 3

Author(s):

Wei-Ying Jen ◽

Young Seok Jeon ◽

Pipin Kojodjojo ◽

Eleen Hui Er Lee ◽

Ya Hui Lee ◽

...

Keyword(s):

Pulmonary Embolism ◽

Risk Groups ◽

Severity Index ◽

Cutoff Score ◽

New Model ◽

Derivation Cohort ◽

Prediction Tools ◽

European Society Of Cardiology ◽

Outpatient Settings ◽

Acute Pe

Pulmonary embolism (PE) is associated with mortality. There are many clinical prediction tools to predict early mortality in acute PE but little consensus on which is best. Our study aims to validate existing prediction tools and derive a predictive model that can be applied to all patients with acute PE in both inpatient and outpatient settings. This is a retrospective cohort study of patients with acute PE. For each patient, the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), European Society of Cardiology (ESC), and Angriman scores were calculated. Scores were assessed by the area under the receive-operating curve (AUC) for 30-day, all-cause mortality. To develop a new prognostic model, elastic logistic regression was used on the derivation cohort to estimate β-coefficients of 8 different variables; these were normalized to weigh them. A total of 321 patients (mean age 60±17 years) were included. Overall 30-day mortality was 10.3%. None of the scores performed well; the AUCs for the PESI, sPESI, ESC, and Angriman scores were 0.67 (95% confidence interval [CI], 0.57-0.77), 0.58 (0.48-0.69), 0.65 (0.55-0.75), and 0.67 (0.57-0.76), respectively. Our new prediction model outperformed PESI, with an AUC of 0.82 (95% CI, 0.76-0.88). At a cutoff score of 100, 195 (60.1%) patients were classified as low risk. Thirty-day mortality was 2.1% (95% CI, 0.8%-5.2%) and 23.0% (16.5%-31.1%) for low- and high-risk groups, respectively ( P < .001). In conclusion, we have developed a new model that outperforms existing prediction tools in all comers with PE. However, further validation on external cohorts is required before application.

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Developing a scoring tool to estimate the risk of deterioration for normotensive patients with acute pulmonary embolism on admission

10.21203/rs.3.rs-50644/v3 ◽

2020 ◽

Author(s):

Yizhuo Gao ◽

Chao Ji ◽

Hongyu Zhao ◽

Jun Han ◽

Haitao Shen ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Clinical Laboratory ◽

Systolic Pressure ◽

Adverse Outcomes ◽

Web Based ◽

Derivation Cohort ◽

Risk Scoring ◽

Scoring Tool ◽

Acute Pe

Abstract Background: It is important to identify deterioration in normotensive patients with acute pulmonary embolism (PE). This study aimed to develop a tool for predicting deterioration among normotensive patients with acute PE on admission.Methods: Clinical, laboratory, and computed tomography parameters were retrospectively collected for normotensive patients with acute PE who were treated at a Chinese center from January 2011 to May 2020 on admission into the hospital. The endpoint of the deterioration was any adverse outcome within 30 days. Eligible patients were randomized 2:1 to derivation and validation cohorts, and a nomogram was developed and validated by the aforementioned cohorts, respectively. The areas under the curves (AUCs) with 95% confidence intervals (CIs) were calculated. A risk-scoring tool for predicting deterioration was applied as a web-based calculator.Results: The 845 eligible patients (420 men, 425 women) had an average age of 60.05±15.43 years. Adverse outcomes were identified for 81 patients (9.6%). The nomogram for adverse outcomes included heart rate, systolic pressure, N-terminal-pro brain natriuretic peptide, and ventricle/atrial diameter ratios at 4-chamber view, which provided AUC values of 0.925 in the derivation cohort (95% CI: 0.900–0.946, p<0.001) and 0.900 in the validation cohort (95% CI: 0.883–0.948, p<0.001). A risk-scoring tool was published as a web-based calculator (https://gaoyzcmu.shinyapps.io/APE9AD/).Conclusions: We developed a web-based scoring tool that may help predict deterioration in normotensive patients with acute PE.

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Developing a scoring tool to estimate the risk of deterioration for normotensive patients with acute pulmonary embolism on admission

10.21203/rs.3.rs-50644/v2 ◽

2020 ◽

Author(s):

Yizhuo Gao ◽

Chao Ji ◽

Hongyu Zhao ◽

Jun Han ◽

Haitao Shen ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Clinical Laboratory ◽

Systolic Pressure ◽

Adverse Outcomes ◽

Web Based ◽

Derivation Cohort ◽

Risk Scoring ◽

Scoring Tool ◽

Acute Pe

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Validation of the Pulmonary Embolism Severity Index for risk stratification after acute pulmonary embolism in a cohort of patients in Brazil

Jornal Brasileiro de Pneumologia ◽

10.1590/1806-3713/e20170251 ◽

2019 ◽

Vol 45 (1) ◽

Cited By ~ 2

Author(s):

Leonardo de Araujo Soriano ◽

Talita Tavares Castro ◽

Kelvin Vilalva ◽

Marcos de Carvalho Borges ◽

Antonio Pazin-Filho ◽

...

Keyword(s):

Cluster Analysis ◽

Pulmonary Embolism ◽

Mortality Rate ◽

Risk Stratification ◽

Acute Pulmonary Embolism ◽

Severity Index ◽

Original Version ◽

Risk Class ◽

Kaplan Meier ◽

Acute Pe

ABSTRACT Objective: To validate the Pulmonary Embolism Severity Index (PESI), which was developed for risk stratification after acute pulmonary embolism (PE), for use in Brazil. Methods: This was a single-center retrospective study involving patients admitted to the emergency department with acute PE. The original and simplified versions of the PESI were calculated using hospital admission data from medical records. The outcome measure was the overall 30-day mortality rate. Results: We included 123 patients. The mean age was 57 ± 17 years, and there was a predominance of females, who accounted for 60% of the cohort. There were 28 deaths, translating to an overall 30-day mortality rate of 23%. In the cluster analysis by risk class, overall 30-day mortality was 2.40% for classes I-II, compared with 20.00% for classes III-IV-V (relative risk [RR] = 5.9; 95% CI: 1.88-18.51; p = 0.0002). When we calculated overall 30-day mortality using the simplified version (0 points vs. ≥ 1 point), we found it to be 3.25% for 0 points and 19.51% for ≥ 1 point (RR = 2.38; 95% CI: 0.89-6.38; p = 0.06). Using the original version, a survival analysis showed that risk classes I and II presented similar Kaplan-Meier curves (p = 0.59), as did risk classes III, IV, and V (p = 0.25). However, the curve of the clusters based on the original version, showed significantly higher mortality in the III-IV-V classes than in the I-II classes (RR = 7.63; 95% CI: 2.29-25.21; p = 0.0001). The cluster analysis based on the original version showed a greater area under the ROC curve than did the analysis based on the simplified version (0.70; 95% CI: 0.62-0.77 vs. 0.60; 95% CI: 0.51-0.67; p = 0.05). Conclusions: The PESI adequately predicted the prognosis after acute PE in this sample of the population of Brazil. The cluster analysis based on the original version is the most appropriate analysis in this setting.

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Diagnostic accuracy of magnetic resonance angiography for acute pulmonary embolism - a systematic review and meta-analysis

VASA ◽

10.1024/0301-1526/a000509 ◽

2016 ◽

Vol 45 (2) ◽

pp. 149-154 ◽

Cited By ~ 2

Author(s):

Jie Li ◽

Lei Feng ◽

Jiangbo Li ◽

Jian Tang

Keyword(s):

Pulmonary Embolism ◽

Magnetic Resonance ◽

Magnetic Resonance Angiography ◽

Diagnostic Accuracy ◽

Acute Pulmonary Embolism ◽

Meta Analysis ◽

Likelihood Ratios ◽

Summary Receiver Operating Characteristic ◽

Acute Pe ◽

Limited Sensitivity

Abstract. Background: The aim of this meta-analysis was to evaluate the diagnostic accuracy of magnetic resonance angiography (MRA) for acute pulmonary embolism (PE). Methods: A systematic literature search was conducted that included studies from January 2000 to August 2015 using the electronic databases PubMed, Embase and Springer link. The summary receiver operating characteristic (SROC) curve, sensitivity, specificity, positive likelihood ratios (PLR), negative likelihood ratios (NLR), and diagnostic odds ratio (DOR) as well as the 95 % confidence intervals (CIs) were calculated to evaluate the diagnostic accuracy of MRA for acute PE. Meta-disc software version 1.4 was used to analyze the data. Results: Five studies were included in this meta-analysis. The pooled sensitivity (86 %, 95 % CI: 81 % to 90 %) and specificity (99 %, 95 % CI: 98 % to 100 %) demonstrated that MRA diagnosis had limited sensitivity and high specificity in the detection of acute PE. The pooled estimate of PLR (41.64, 95 % CI: 17.97 to 96.48) and NLR (0.17, 95 % CI: 0.11 to 0.27) provided evidence for the low missed diagnosis and misdiagnosis rates of MRA for acute PE. The high diagnostic accuracy of MRA for acute PE was demonstrated by the overall DOR (456.51, 95 % CI: 178.38 - 1168.31) and SROC curves (AUC = 0.9902 ± 0.0061). Conclusions: MRA can be used for the diagnosis of acute PE. However, due to limited sensitivity, MRA cannot be used as a stand-alone test to exclude acute PE.

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Levosimendan, milrinone and dobutamine in acute experimental pulmonary embolism

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.193 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

MD Lyhne ◽

SJ Dragsbaek ◽

JV Hansen ◽

JG Schultz ◽

A Andersen ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Cardiovascular Effects ◽

Right Heart Catheterization ◽

Mechanical Work ◽

Heart Catheterization ◽

Funding Sources ◽

Mean Pulmonary Arterial Pressure ◽

Acute Pe ◽

Rv Function

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Laerdal Foundation for Acute Medicine, Novo Nordisk Foundation Background/Introduction: Acute pulmonary embolism (PE) is a frequent condition in acute cardiac care and is potentially fatal. Cause of death is right ventricular (RV) failure due to increased RV afterload from both pulmonary vascular obstruction and vasoconstriction. Inodilators are interesting drugs of choice as they may improve RV function and lower its afterload. Purpose We aimed to investigate the cardiovascular effects of three clinically relevant inodilators: levosimendan, milrinone and dobutamine in acute PE. Methods We conducted a randomized, blinded, animal study using 18 female pigs. Animals received large autologous PE until doubling of baseline mean pulmonary arterial pressure and were randomized to four logarithmically increasing doses of each inodilator. Effects were evaluated with bi-ventricular pressure-volume loop recordings, right heart catheterization and blood gas analyses. Results Induction of PE increased RV afterload and pulmonary pressure (p < 0.05) causing RV dysfunction. Levosimendan and milrinone showed beneficial hemodynamic profiles by lowering RV pressures and volume (p < 0.001) and improved RV function and cardiac output (p < 0.05) without increasing RV mechanical work. Dobutamine increased RV pressure and function (p < 0.01) but at a cost of increased mechanical work at the highest doses, showing an adverse hemodynamic profile. See Figure. Conclusion(s): In a porcine model of acute PE, levosimendan and milrinone reduced RV afterload and improved RV function, whereas dobutamine at higher doses increased RV afterload and RV mechanical work. The study motivates clinical testing of inodilators in patients with acute PE and RV dysfunction. Abstract Figure. Inodilators in acute pulmonary embolism

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Computed Tomography Pulmonary Perfusion for Prediction of Short-Term Clinical Outcome in Acute Pulmonary Embolism

TH Open ◽

10.1055/s-0041-1723782 ◽

2021 ◽

Vol 05 (01) ◽

pp. e66-e72

Author(s):

Lisette F. van Dam ◽

Lucia J. M. Kroft ◽

Menno V. Huisman ◽

Maarten K. Ninaber ◽

Frederikus A. Klok

Keyword(s):

Computed Tomography ◽

Pulmonary Embolism ◽

Predictive Value ◽

Acute Pulmonary Embolism ◽

Clinical Presentation ◽

Reperfusion Therapy ◽

Pulmonary Perfusion ◽

Short Term ◽

Acute Pe ◽

Related Mortality

Abstract Background Computed tomography pulmonary angiography (CTPA) is the imaging modality of choice for the diagnosis of acute pulmonary embolism (PE). With computed tomography pulmonary perfusion (CTPP) additional information on lung perfusion can be assessed, but its value in PE risk stratification is unknown. We aimed to evaluate the correlation between CTPP-assessed perfusion defect score (PDS) and clinical presentation and its predictive value for adverse short-term outcome of acute PE. Patients and Methods This was an exploratory, observational study in 100 hemodynamically stable patients with CTPA-confirmed acute PE in whom CTPP was performed as part of routine clinical practice. We calculated the difference between the mean PDS in patients with versus without chest pain, dyspnea, and hemoptysis and 7-day adverse outcome. Multivariable logistic regression analysis and likelihood-ratio test were used to assess the added predictive value of PDS to CTPA parameters of right ventricle dysfunction and total thrombus load, for intensive care unit admission, reperfusion therapy and PE-related death. Results We found no correlation between PDS and clinical symptoms. PDS was correlated to reperfusion therapy (n = 4 with 16% higher PDS, 95% confidence interval [CI]: 3.5–28%) and PE-related mortality (n = 2 with 22% higher PDS, 95% CI: 4.9–38). Moreover, PDS had an added predictive value to CTPA assessment for PE-related mortality (from Chi-square 14 to 19, p = 0.02). Conclusion CTPP-assessed PDS was not correlated to clinical presentation of acute PE. However, PDS was correlated to reperfusion therapy and PE-related mortality and had an added predictive value to CTPA-reading for PE-related mortality; this added value needs to be demonstrated in larger studies.

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Increased Brain Natriuretic Peptide as a Marker for Right Ventricular Dysfunction in Acute Pulmonary Embolism

Thrombosis and Haemostasis ◽

10.1055/s-0037-1616050 ◽

2001 ◽

Vol 86 (11) ◽

pp. 1193-1196 ◽

Cited By ~ 107

Author(s):

Igor Tulevski ◽

Alexander Hirsch ◽

Bernd-Jan Sanson ◽

Hans Romkes ◽

Ernst van der Wall ◽

...

Keyword(s):

Pulmonary Embolism ◽

Brain Natriuretic Peptide ◽

Right Ventricular ◽

Natriuretic Peptide ◽

Acute Pulmonary Embolism ◽

Prognostic Significance ◽

Systolic Pressure ◽

Clinical Importance ◽

Acute Pe ◽

Rv Function

SummaryRight ventricular (RV) function is of major prognostic significance in patients with acute pulmonary embolism (PE). The aim of the present study was to evaluate the role of neurohormone plasma brain natriuretic peptide (BNP) in assessing RV function in patients with acute PE.BNP levels were measured in 16 consecutive patients with acute PE as diagnosed by high probability lung scintigraphy or pulmonary angiography. Twelve healthy age-matched volunteers served as controls. All 16 patients underwent standard echocardiography and blood tests during the first hour of presentation. In the patient group, survival was studied for a period of 30 days. Plasma BNP levels in patients with acute PE were higher than in controls (7.2 [95% CI 0.4 to 144.6] versus 1.4[95% CI 0.4 to 4.6] pmol/L, p = 0.0008). Plasma BNP was significantly higher in 5 patients with RV dysfunction compared to 11 patients with normal RV function (40.2 [95% CI 7.5 to 214.9] versus 3.3 [95% CI 0.4 to 24.9] pmol/L, p = 0.0003). RV systolic pressure was not significantly correlated with BNP (r = 0.42, p = ns).In conclusion, plasma BNP neurohormone levels might be of clinical importance as a supplementary tool for assessment of RV function in patients with acute PE.

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