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

2018 ◽  
Vol 24 (9_suppl) ◽  
pp. 277S-284S ◽  
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.

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

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M C Vedovati ◽  
L A Cimini ◽  
L Pierpaoli ◽  
S Vanni ◽  
M Cotugno ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Severity Index ◽  
Discriminatory Power ◽  
Clinical Model ◽  
Derivation Cohort ◽  
Model Study ◽  
Lemeshow Test ◽  
Respiratory Index ◽  
Acute Pe

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.

scholarly journals Is the Pulmonary Embolism Severity Index Being Routinely Used in Clinical Practice?

Thrombosis ◽  
2015 ◽  
Vol 2015 ◽  
pp. 1-5 ◽  
Author(s):  
Ali Shafiq ◽  
Hamza Lodhi ◽  
Zaheer Ahmed ◽  
Ata Bajwa
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Hospital Stay ◽  
Length Of Hospital Stay ◽  
Risk Groups ◽  
Severity Index ◽  
Low Risk ◽  
Significant Difference ◽  
Risk Patients ◽  
Acute Pe

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.

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

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.

scholarly journals Does Pulmonary Embolism Differ Between Genders in Terms of Clinical, Laboratory Findings, Prognosis and Mortality?

2020 ◽  
Author(s):  
Damla Serçe Unat ◽  
Aysu Ayrancı ◽  
Gulru Polat ◽  
Gülistan Karadeniz ◽  
Fatma Demirci Üçsular ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Laboratory ◽  
Severity Index ◽  
Early Mortality ◽  
European Respiratory Society ◽  
Laboratory Findings ◽  
Significant Difference ◽  
Male Patients ◽  
European Society Of Cardiology

INTRODUCTION: Pulmonary thromboembolism (PTE) is a disease that mortal and hardly diagnosed. Since findings of PTE are nonspesific diagnosed can be so hard sometimes. Major risk factors are malignancy, immobility, previous surgery, thrombophilia, advanced age, and genetic factors. Studies on the relationship between gender and prognosis in PTE have very different results. In this study, we aimed to evaluate gender differences in terms of prognosis, intensive care admission, laboratory, and radiological tests. METHODS: We retrospectively analyzed the data of 348 patients diagnosed with Acute PTE between January 2012 and December 2015. All of these patients were patients who applied to the emergency department of our center, which is a third step chest diseases hospital. We used the PTE guideline jointly designed by the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) for prognosis classifications. RESULTS: The mean age of the patients was 62.7, while the male patients were younger. Women's sPESI scores and mean ages were observed higher than men. Although women had more bad prognostic factors, no significant difference was found between both genders in terms of early mortality. DISCUSSION AND CONCLUSION: Although there is a difference between mean age and simplified Pulmonary Embolism Severity Index (sPESI) scores; no difference in early mortality between men and women. Gender studies in PTE are an area that is open to new studies, since the studies conducted on this subject give quite different results and these results may affect the follow-up protocols.

Measurement of High-Sensitivity Cardiac Troponin in Pulmonary Embolism: Useful Test or a Clinical Distraction

2019 ◽  
Vol 45 (08) ◽  
pp. 784-792
Author(s):  
Giuseppe Lippi ◽  
Emmanuel J. Favaloro ◽  
Peter Kavsak
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Cardiac Troponin ◽  
Laboratory Tests ◽  
High Sensitivity ◽  
Severity Index ◽  
Adverse Outcomes ◽  
Incremental Value ◽  
Risk Patients ◽  
Acute Pe

AbstractThe ability to predict death or other unfavorable outcomes after an acute pulmonary embolism (PE) is challenging, with current available risk score models having relatively unsatisfactory prognostic performance in this area. For example, the simplified pulmonary embolism severity index (sPESI), the most frequently used stratification tool, misclassifies a significant percentage of low- and high-risk patients. This gap in care, along with the increasing clinical availability of high-sensitivity cardiac troponin (hs-cTn) laboratory tests and the recent emphasis on detecting myocardial injury, may foster further evaluation of hs-cTn testing in patients with acute PE. Our analysis of the current scientific literature on hs-cTn in patients with acute PE identified that hs-cTn testing may provide valuable information for predicting future adverse outcomes and mortality, independently from baseline clinical risk assessment. Although the risk of an adverse event is indeed higher in patients with higher sPESI scores, cTns retain their prognostic value also in those at low risk, suggesting that a combination of hs-cTn with sPESI may provide an incremental value over assessment of either variable alone. Accordingly, the future development of updated risk stratification models, with the inclusion of laboratory tests such as hs-cTn, may represent an enhanced approach for risk stratification in patients with acute PE. Additional research, however, is needed to verify whether the combination of cTns, specifically as measured with hs-cTn assays, with other biomarkers may further improve the current capacity to efficiently manage patients with acute PE.

scholarly journals Contemporary clinical management of acute pulmonary embolism: the COPE study

2022 ◽  
Author(s):  
Cecilia Becattini ◽  
Giancarlo Agnelli ◽  
Aldo Pietro Maggioni ◽  
Francesco Dentali ◽  
Andrea Fabbri ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Acute Pulmonary Embolism ◽  
Management Strategies ◽  
Treatment Strategies ◽  
Low Risk ◽  
Contemporary Management ◽  
Secondary Study ◽  
European Society Of Cardiology ◽  
Acute Pe

Abstract Background New management, risk stratification and treatment strategies have become available over the last years for patients with acute pulmonary embolism (PE), potentially leading to changes in clinical practice and improvement of patients’ outcome. Methods The COntemporary management of Pulmonary Embolism (COPE) is a prospective, non-interventional, multicentre study in patients with acute PE evaluated at internal medicine, cardiology and emergency departments in Italy. The aim of the COPE study is to assess contemporary management strategies in patients with acute, symptomatic, objectively confirmed PE concerning diagnosis, risk stratification, hospitalization and treatment and to assess rates and predictors of in-hospital and 30-day mortality. The composite of death (either overall or PE-related) or clinical deterioration at 30 days from the diagnosis of PE, major bleeding occurring in hospital and up to 30 days from the diagnosis of PE and adherence to guidelines of the European Society of Cardiology (ESC) are secondary study outcomes. Participation in controlled trials on the management of acute PE is the only exclusion criteria. Expecting a 10–15%, 3% and 0.5% incidence of death for patients with high, intermediate or low-risk PE, respectively, it is estimated that 400 patients with high, 2100 patients with intermediate and 2500 with low-risk PE should be included in the study. This will allow to have about 100 deaths in study patients and will empower assessment of independent predictors of death. Conclusions COPE will provide contemporary data on in-hospital and 30-day mortality of patients with documented PE as well as information on guidelines adherence and its impact on clinical outcomes. Trail registration NCT number: NCT03631810.

High mortality in patients presenting with acute pulmonary embolism and elevated INR not on anticoagulant therapy

2016 ◽  
Vol 115 (06) ◽  
pp. 1191-1199 ◽  
Author(s):  
Christopher Wong ◽  
Jerrett Lau ◽  
Vincent Chow ◽  
Vivien Chen ◽  
Andy Yong ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Anticoagulant Therapy ◽  
Clinical Decision Making ◽  
Prognostic Significance ◽  
Severity Index ◽  
Clinical Decision ◽  
Tertiary Hospital ◽  
Risk Of Death ◽  
Net Reclassification Improvement ◽  
Acute Pe

SummaryThe prognostic significance of patients presenting with pulmonary embolism (PE) and elevated International Normalised Ratio (INR) not on anticoagulant therapy has not been described. We investigated whether these patients had higher mortality compared to patients with normal INR. A retrospective study of patients admitted to a tertiary hospital with acute PE from 2000 to 2012 was undertaken, with study outcomes tracked using a state-wide death registry. Patients were excluded if they were taking anticoagulants or had inadequate documentation of their INR and medication status. Of the 1,039 patients identified, 94 (9 %) had an elevated INR (> 1.2) in the absence of anticoagulant use. These patients had higher mortality at six months follow-up (26 % vs 6 %, p< 0.001) compared to controls (INR ≤ 1.2). An INR > 1.2 at diagnosis was an independent predictor of death at six months post-PE (hazard ratio [HR] 2.9, 95 % confidence interval [CI] 1.8–4.7, p< 0.001). The addition of INR to a multivariable model that included the simplified pulmonary embolism severity index (sPESI), chest pain, and serum sodium led to a significant net reclassification improvement estimated at 8.1 %. The final model’s C statistic increased significantly by 0.04 (95 % CI 0.01–0.08, p=0.03) to 0.83 compared to sPESI alone (0.79). In summary, patients presenting with acute PE and elevated INR while not on anticoagulant therapy appear to be at high risk of death. Future validation studies in independent cohorts will clarify if this novel finding can be usefully incorporated into clinical decision making in patients with acute PE.

Validation of the 2019 European Society of Cardiology risk stratification algorithm for pulmonary embolism in normotensive elderly patients

2021 ◽  
Author(s):  
Jeanne Moor ◽  
Christine Baumgartner ◽  
Marie Méan ◽  
Odile Stalder ◽  
Andreas Limacher ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
European Society ◽  
Risk Groups ◽  
Adverse Outcomes ◽  
Low Risk ◽  
Receiver Operating Curve ◽  
European Society Of Cardiology ◽  
Related Mortality ◽  
Overall Mortality

Background: The 2019 European Society of Cardiology (ESC) guidelines recommend evaluation for right ventricular dysfunction in all normotensive patients with acute pulmonary embolism (PE). We compared the predictive performance of the 2019 and 2014 ESC risk stratification algorithms and the Pulmonary Embolism Severity Index (PESI). Methods: We performed a post-hoc analysis of normotensive patients aged ≥65 years with acute PE from a prospective cohort. The primary outcome was overall mortality; secondary outcomes were PE-related mortality and adverse outcomes (PE-related death, cardiopulmonary resuscitation, intubation, catecholamine use, recurrent venous thromboembolism) at 30 days. We assessed outcomes in intermediate-high, intermediate-low, and low risk groups according to the 2019 and 2014 ESC algorithms and the PESI. Discriminative power was compared using the area under the receiver operating curve (AUC). Results: Among 419 patients, 14 (3.3%) died (7 from PE) and 16 (3.8%) had adverse outcomes within 30 days. The 2019 ESC algorithm classified more patients as intermediate-high risk (45%) than the 2014 ESC algorithm (24%) or PESI (37%), and only 19% as low risk (32% with 2014 ESC or PESI). Discriminatory power for overall mortality was lower with the 2019 ESC algorithm (AUC 63.6%), compared to the 2014 ESC algorithm (AUC 71.5%) or PESI (AUC 75.2%), although the difference did not reach statistical significance (p=0.063). Discrimination for PE-related mortality and adverse outcomes was similar. Conclusions: While categorizing more patients in higher-risk groups, the 2019 ESC algorithm for PE did not improve prediction of short-term outcomes compared to the 2014 ESC algorithm or the PESI.

scholarly journals Prognostic stratification of pulmonary embolism: what does it change from 2014 European Society of Cardiology guidelines?

2014 ◽  
Vol 5 (4) ◽  
pp. 153-160
Author(s):  
Luca Masotti ◽  
Giancarlo Landini ◽  
Gianni Lorenzini ◽  
Irene Chiti ◽  
Grazia Panigada
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Mortality Risk ◽  
Prognostic Model ◽  
Early Mortality ◽  
Low Risk ◽  
Intermediate Risk ◽  
Prognostic Stratification ◽  
European Society Of Cardiology ◽  
Acute Pe

Prognostic stratification is of utmost importance for clinical management of acute pulmonary embolism (PE). Clinical presentation, echocardiography and biomarkers represented the key points on which recommendations of European Society of Cardiology (ESC) released in 2008 were based. In fact, in 2008 the ESC prognostic model suggested to divide acute PE in high risk, heamodynamically unstable, based on presentation with shock or hypotension, and non high risk, haemodynamically stable. The non high risk PE was divided in intermediate rand low risk PE based on echocardiographicand biomarkers signs of right heart dysfunction (RHD) and myocardial damage. This approach was not an academic speculation but permitted to define the early mortality risk (>15% in high risk, 3-15% in intermediate risk, <1% in low risk) and bring the most appropriate treatment. Over the years it became clear that co-morbidity influenced the early mortality risk and may define better the low mortality risk. Practical clinical scores, such as the Pulmonary Embolism Severity Index, PESI, in its original or simplified version, demonstrated to have high prognostic power to identify high (early mortality risk over 10%) and low risk (early mortality risk ≤ 1%) patients. Furthermore, it has become clear that the combination of ESC prognostic model, based on haemodynamics, and clinical prognostic scores may improve the prognostic stratification of acute PE, especially for patients with intermediate risk in whom the range of early mortality risk is wide The latest version of ESC recommendations on management of acute PE released in August 2014 go toward this direction and suggest to divide the non high risk PE in low or intermediate risk taking in account the PESI score. In this review we describe the prognostic strategy of acute PE suggested from the latest version of ESC recommendations.

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