scholarly journals Renal dysfunction improves risk stratification and may call for a change in the management of intermediate- and high-risk acute pulmonary embolism: results from a multicenter cohort study with external validation

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Romain Chopard ◽  
David Jimenez ◽  
Guillaume Serzian ◽  
Fiona Ecarnot ◽  
Nicolas Falvo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Renal Dysfunction ◽  
Prognostic Model ◽  
External Validation ◽  
Low Risk ◽  
Model Fit ◽  
The Impact ◽  
Acute Pe

Abstract Background Renal dysfunction influences outcomes after pulmonary embolism (PE). We aimed to determine the incremental value of adding renal dysfunction, defined by estimated glomerular filtration rate (eGFR), on top of the European Society of Cardiology (ESC) prognostic model, for the prediction of 30-day mortality in acute PE patients, which in turn could lead to the optimization of acute PE management. Methods We performed a multicenter, non-interventional retrospective post hoc analysis based on a prospectively collected cohort including consecutive confirmed acute PE stratified per ESC guidelines. We first identified which of three eGFR formulae most accurately predicted death. Changes in global model fit, discrimination, calibration and reclassification parameters were evaluated with the addition of eGFR to the prognostic model. Results Among 1943 patients (mean age 67.3 (17.1), 50.4% women), 107 (5.5%) had died at 30 days. The 4-variable Modification of Diet in Renal Disease (eGFRMDRD4) formula predicted death most accurately. In total, 477 patients (24.5%) had eGFRMDRD4 < 60 ml/min. Observed mortality was higher for intermediate–low-risk and high-risk PE in patients with versus without renal dysfunction. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC model. Reclassification parameters were significantly increased, yielding 18% reclassification of predicted mortality (p < 0.001). Predicted mortality reclassifications across risk categories were as follows: 63.1% from intermediate–low risk to eGFR-defined intermediate–high risk, 15.8% from intermediate–high risk to eGFR-defined intermediate–low risk, and 21.0% from intermediate–high risk to eGFR-defined high risk. External validation in a cohort of 14,234 eligible patients from the RIETE registry confirmed our findings with a significant improvement of Harrell’s C index and reclassification parameters. Conclusion The addition of eGFRMDRD4-derived renal dysfunction on top of the prognostic algorithm led to risk reclassification within the intermediate- and high-risk PE categories. The impact of risk stratification integrating renal dysfunction on therapeutic management for acute PE requires further studies.

Renal function improves mortality prediction in acute pulmonary embolism: results of a multicentre cohort study with external validation in the RIETE registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Chopard ◽  
D Jimenez ◽  
G Serzian ◽  
F Ecarnot ◽  
N Falvo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Renal Function ◽  
High Risk ◽  
Renal Dysfunction ◽  
External Validation ◽  
Mortality Prediction ◽  
Model Fit ◽  
Funding Source ◽  
Risk Of Death ◽  
Acute Pe

Abstract Background Renal dysfunction may influence outcomes after pulmonary embolism (PE). We determined the incremental value of adding renal function impairment (estimated glomerular filtration rate, eGFR &lt;60 ml/min/1.73m2) on top of the 2019 ESC prognostic model, for the prediction of 30-day all-cause mortality in acute PE patients from a prospective, multicenter cohort. Methods and results We identified which of three eGFR formulae predicted death most accurately. Changes in global model fit, discrimination, calibration and net reclassification index (NRI) were evaluated with addition of eGFR. We prospectively included consecutive adult patients with acute PE diagnosed as per ESC guidelines. Among 1,943 patients, (mean age 67.3±17.1, 50.4% women), 107 (5.5% (95% CI 4.5–6.5%)) died during 30-day follow-up. The eGFRMDRD4 formula was the most accurate for prediction of death. The observed mortality rate was higher for intermediate-low risk (OR 1.8, 95% CI 1.1–3.4) and high-risk PE (OR 10.3, 95% CI 3.6–17.3), and 30-day bleeding was significantly higher (OR 2.1, 95% CI 1.3–3.5) in patients with vs without eGFRMDRD4 &lt;60 ml/min/1.73m2. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC models. NRI was significantly improved (p&lt;0.001), with 18% reclassification of predicted mortality, specifically in intermediate and high-risk PE. External validation using data from the RIETE registry confirmed our findings (Table). Conclusion Addition of eGFRMDRD4-derived renal dysfunction on top of the ESC prognostic algorithm yields significant reclassification of risk of death in intermediate and high-risk PE. Impact on therapy remains to be determined. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer Alliance, Bayer Healthcare

P6464Acute pulmonary embolism in Argentina. CONAREC XX registry

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
I M Cigalini ◽  
C E Scatularo ◽  
J C C Jauregui ◽  
J I Ortego ◽  
D Cornejo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Hemodynamic Instability ◽  
Low Risk ◽  
P Value ◽  
Acute Pe

Abstract Background Pulmonary embolism (PE) represents the third cause of cardiovascular death and one of the leading causes of preventable in-hospital mortality. However, there is lack of information about this entity in our country. Purpose To describe baseline characteristics, in-hospital evolution and treatments among patients (P) admitted for acute PE in Argentina. Methods A prospective multicentric registry of P with acute PE was conducted in 75 academic centers between October 2016 and November 2017. Conventional analysis was used for descriptive and comparative statistics, with a p value <0.05 considered as significant. Cross audit was performed at 20% of participating centers. Results We included 684 consecutive P with an average age of 63,8 years (SD 16,8), with slight majority of female sex (57%). PE was the reason for admission in 484 (71%) of the cases; 68% of those others who developed PE as a complication during hospital stay were under adequate venous thromboembolism prophylaxis. The most frequent predisposing factors were obesity (34%), recent hospitalization (34%), transient rest (30%) and active cancer (22%). Multislice computed tomography was the diagnostic method of choice (81%). An echocardiogram was performed in 625 P (91%), showing right ventricular dilatation or dysfunction in 41% and 35% of the cases, respectively. After initial diagnosis, P were stratified as low risk (24%), intermediate-low risk (34%), intermediate-high risk (27%) and high risk (15%). Anticoagulation was indicated in 661 (97%), mainly with low-molecular-weight heparins (LMWH) (59%) as initial strategy. Reperfusion with either thrombolytics or mechanical therapies was performed in 91 (13%) cases. However, only 50 of the 102 P who presented with hemodynamic instability received any reperfusion therapy (49%). Overall in-hospital mortality was 12%, mainly related to PE (51%), with significant differences according to risk stratification (p<0,01) (Figure 1). 579 out of 601 survivors received anticoagulants at discharge: 60% vitamin K antagonists, 21% LMWH and 19% direct oral anticoagulants (49% Rivaroxaban, 34% Apixaban and 17% Dabigatran). Mortality according risk stratification Conclusions PE presents with high in-hospital mortality in our setting mainly due to the embolic event. This finding could be related to a low use of reperfusion therapies in P with hemodynamic instability, reflecting low adherence to guideline recommendations even in academic centers. This issue should be taken into consideration to improve PE prognosis in Argentina.

scholarly journals Contemporary Clinical Management and Course of ACUTE Pulmonary Embolism: The COPE Study

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 3230-3230
Author(s):  
Cecilia Becattini ◽  
Giancarlo Agnelli ◽  
Aldo P Maggioni ◽  
Francesco Dentali ◽  
Andrea Fabbri ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Major Bleeding ◽  
Acute Pulmonary Embolism ◽  
Low Risk ◽  
Intermediate Risk ◽  
Bayer Healthcare ◽  
Risk Patients ◽  
Acute Pe

Abstract Background. New management strategies, risk stratification procedures and treatments have become available over the last years for patients with acute pulmonary embolism (PE), leading to changes in clinical practice and potentially influencing patient's course and outcome. Methods: The COntemporary management of Pulmonary Embolism (COPE) is an academical prospective, non-interventional, multicentre study in patients with confirmed acute symptomatic PE. In-hospital and 30-day mortality were the co-primary study outcomes. At first evaluation, patients were categorized at low-risk (simplified PESI [sPESI]=0), intermediate-risk (further classified based presence/absence of increased levels and right ventricle dysfunction [RVD] at echocardiography) and high-risk (shock or cardiac arrest). Results. Among 5213 study patients, PE was confirmed by computed tomography in 96.3% and at least one test for risk stratification was obtained in more than 80% (81% echocardiography, 83% troponin, 56% brain natriuretic peptide/NT-pro BNP). Among 4885 patients entering the Emergency Department for acute PE, 1.2% were managed as outpatients and 5.8% by short-observation. In-hospital, 289 patients underwent reperfusion (5.5%); at discharge, 6.7% received a vitamin K antagonist and 75.6% a direct oral anticoagulant. Median duration of hospitalization was 7 days (IQR 5-12 days). Overall in-hospital mortality was 3.4% (49% due to PE, 16% cancer and 4.5% major bleeding) and 30-day mortality 4.8% (36% PE, 28% cancer and 4% major bleeding). In-hospital major bleeding was 2.6%. Death at 30 days occurred in 22.6% of 177 high-risk patients, in 6% of the 3281 intermediate-risk and in 0.5% of 1702 low-risk patients. Time to death at 30 days in patients at low, intermediate and high risk for death is reported in the Figure. Conclusions: COPE is the largest ever cohort of patients with acute PE. In this contemporary scenario, the majority of patients received CT for diagnosis, at least one test for risk stratification and direct oral anticoagulants as long-term treatment. Short term death remains not negligible in patients with high and intermediate-risk PE. Figure 1 Figure 1. Disclosures Becattini: Bristol Myers Squibb: Honoraria; Daiichi Sankyo: Honoraria; Bayer HealthCare: Honoraria. Agnelli: Bristol Myers Squibb: Honoraria; Pfizer: Honoraria; Daiichi Sankyo: Honoraria; Bayer HealthCare: Honoraria. Dentali: Daiichi Sankyo: Honoraria; Bayer: Honoraria; Sanofi: Honoraria; Pfizer: Honoraria; Bristol-Myers Squibb: Honoraria; Novartis: Honoraria; Boehringer: Honoraria; Alfa Sigma: Honoraria.

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.

External Validation of Generic and Cancer-Specific Risk Stratification Criteria for Predicting 30-Day Mortality in Patients Presenting with Pulmonary Embolism and Active Cancer

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 4730-4730
Author(s):  
Jonathan T Caranfa ◽  
Erin R Weeda ◽  
Craig I Coleman ◽  
Simon B. Zeichner ◽  
Christine G Kohn
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Research Funding ◽  
External Validation ◽  
Low Risk ◽  
Vein Thrombosis ◽  
Social Security Death Index ◽  
Deep Vein ◽  
Active Cancer

Abstract Introduction: The Hestia criteria has been established as a highly sensitive prognostic tool used by clinicians to identify newly diagnosed pulmonary embolism (PE) patients from the general population at low vs. high risk of early (30 day) mortality. Font et al. applied similar risk stratification criteria in a population restricted to PE patients with cancer. We evaluated the performance of the generic Hestia tool and cancer-specific criteria by Font et al. for predicting 30-day post-PE mortality in patients with active cancer. Methods: We identified consecutive, adult, objectively confirmed PE patients with active cancer presenting to the emergency department at our institution from 11/2010-1/2014. We calculated the proportion of patients categorized as low-risk by each set of criteria and determined the accuracy of the criteria for predicting 30-day all-cause mortality. Mortality was determined through Social Security Death Index searches. Results: A total of 124 patients with PE and active cancer (mean age 66.2 years, 46.0% with concurrent deep vein thrombosis, 49.2% with metastatic disease and 46.8%, 16.9% and 10.4% receiving chemotherapy, radiation or both, respectively) were included. Mortality at 30-days occurred in 25 (20.2%) patients. The Hestia tool had a sensitivity of 100% but classified <19% of patients as low-risk; while criteria developed by Font et al. had a sensitivity of 88.0% and classified 41.1% of patients as low-risk (Table). The most common reason patients were classified as high-risk by Hestia but not the criteria from Font et al. was the requirement for oxygen (O2) therapy to maintain an O2 saturation >90% for >24 hours (n=19). Conclusion: In this external validation study, both the generic Hestia tool and cancer-specific Font et al. risk stratification criteria displayed acceptable sensitivity. Compared to Hestia, the Font et al. criteria classified two times as many patients as low-risk. Larger, prospective studies are needed to confirm our results. Disclosures Coleman: Janssen Pharmaceuticals: Consultancy, Research Funding; Bayer Pharmaceuticals AG: Consultancy, Research Funding; Boehringer-Ingelheim Pharmaceuticals, inc.: Consultancy, Research Funding.

scholarly journals Categorical Assignment of Pulmonary Embolism is a Simple and More Accurate Indicator of Right Ventricular Dysfunction and Short Team Mortality

2019 ◽  
Author(s):  
Yu Lin Chen ◽  
Colin Wright ◽  
Anthony P. Pietropaoli ◽  
Ayman Elbadawi ◽  
Joseph Delehanty ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Right Ventricular ◽  
Myocardial Strain ◽  
Area Under The Curve ◽  
Low Risk ◽  
Short Term ◽  
Short Term Mortality ◽  
Acute Pe

AbstractSeveral risk stratification tools are available to predict short-term mortality in patients with acute pulmonary embolism (PE). Right ventricular (RV) dysfunction, which is common to intermediate and high risk PE, is an independent predictor of mortality and may be a faster and simpler way to assess patient risk in acute care settings. We evaluated 571 patients presenting with acute PE as the primary diagnosis, stratifying them by the Pulmonary Embolism Severity Index (PESI), by the BOVA score, or categorically as low risk (no RV dysfunction by imaging), intermediate risk (RV dysfunction by imaging), or high risk PE (RV dysfunction by imaging with sustained hypotension). Using imaging data to firstly define the presence of RV dysfunction, and plasma cardiac troponin T (cTnT) and NT-proBNP as additional evidence for myocardial strain, we evaluated the PESI and BOVA scoring systems compared to categorical assignment of PE as low risk, submassive, and massive PE. Cardiac biomarkers poorly distinguished between PESI classes and BOVA stages in patients with acute PE. Cardiac TnT and NT-proBNP easily distinguished low risk from submassive PE with an area under the curve (AUC) of 0.84 (95% C.I. 0.73 – 0.95, p< 0.0001), and 0.88 (95% C.I. 0.79-0.97, p< 0.0001), respectively, and low risk from massive PE with an area under the curve (AUC) of 0.89 (95% C.I. 0.78 – 1.00, p< 0.0001), and 0.89 (95% C.I. 0.82-0.95, p< 0.0001), respectively. Predicted short-term mortality by PESI score or BOVA stage was lower than the observed mortality for submassive PE by a two-fold order of magnitude. These data suggest the presence of RV dysfunction in the context of acute PE is sufficient for the purposes of risk stratification, while more complicated risk stratification algorithms may under-estimate short-term mortality risk.

scholarly journals Renal dysfunction in patients with pulmonary embolism: data from the SIRENA register

2021 ◽  
Vol 26 (2S) ◽  
pp. 4422
Author(s):  
M. V. Menzorov ◽  
V. V. Filimonova ◽  
A. D. Erlikh ◽  
O. L. Barbarash ◽  
S. A. Berns ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Renal Dysfunction ◽  
Cox Regression ◽  
Russian Population ◽  
Hospital Death ◽  
Death Risk ◽  
Risk Of Death

Aim. To assess the prevalence, severity and prognostic value of renal dysfunction (RD) in patients with pulmonary embolism (PE) of the Russian population, as well as to determine the RD significance as a marker that improves the predictive ability of current risk stratification systems.Material and methods. From April 2018 to April 2019, patients hospitalized due to PE were sequentially included in the Russian multicenter observational prospective registry SIRENA. RD was diagnosed at a glomerular filtration rate (GFR) <60 ml/ min/1,73 m2. Risk of early (hospital or 30-day) death was stratified in accordance with the current 2019 ESC Clinical Guidelines. During the study, we analyzed inpatient mortality and complication rate.Results. A total of 604 patients (men, 293 (49%); women, 311 (51%)) were in the study. RD was detected in 320 (53%) patients, while severe dysfunction — in 63 (10%) ones. In addition, 71 (12%) patients had high death risk, 364 (61%) — intermediate, 164 (27%) — low. During hospitalization, 107 (18%) patients died, including 32% from the high-risk group, 20% — moderate, and 7% — low. RD in the deceased patients was diagnosed more often, while GFR <50 ml/min/1,73 m2 reliably predicted hospital mortality (sensitivity, 67%; specificity, 72%; AUC=0,72; p<0,001). In patients with simplified Pulmonary Embolism Severity Index (sPESI) of 0 and ≥ 1, the presence of RD led to at least a 2-fold increase in mortality. Multivariate Cox regression revealed that RD is a predictor of in-hospital mortality (hazard ratio (HR), 3,41; 95% confidence interval (CI): 2,15-5,41; p<0,001), regardless of the presence of death risk reclassifies, such as high troponin (HR, 1,31; 95% CI: 0,80-2,14; p=0,28) and right ventricular dysfunction (HR, 1,23; 95% CI: 0,74-2,04; p=0,42).Conclusion. In patients with PE of the Russian population, there is a high incidence of RD, which is diagnosed in every second patient and is severe in 10% of cases. The presence of RD is associated with a significant increase in in-hospital mortality, while the risk of death increases with a decrease in GFR. The addition of RD, considered as a decrease in the estimated GFR <60 ml/min/1,73 m2, to the sPESI improves risk stratification and allows identification of patients at high risk of in-hospital death.

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.

scholarly journals Comparison of risk assessment strategies for not-high-risk pulmonary embolism

2016 ◽  
Vol 47 (4) ◽  
pp. 1170-1178 ◽  
Author(s):  
Lukas Hobohm ◽  
Kristian Hellenkamp ◽  
Gerd Hasenfuß ◽  
Thomas Münzel ◽  
Stavros Konstantinides ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Adverse Outcome ◽  
Troponin T ◽  
Favourable Outcome ◽  
Low Risk ◽  
Fatty Acid Binding ◽  
Increased Risk ◽  
Risk Patients

We compared the prognostic performance of the 2014 European Society of Cardiology (ESC) risk stratification algorithm with the previous 2008 ESC algorithm, the Bova score and the modified FAST score (based on a positive heart-type fatty acid-binding protein (H-FABP) test, syncope and tachycardia, modified using high-sensitivity troponin T instead of H-FABP) in 388 normotensive pulmonary embolism patients included in a single-centre cohort study.Overall, 25 patients (6.4%) had an adverse 30-day outcome. Regardless of the score or algorithm used, the rate of an adverse outcome was highest in the intermediate-high-risk classes, while all patients classified as low-risk had a favourable outcome (no pulmonary embolism-related deaths, 0–1.4% adverse outcome). The area under the curve for predicting an adverse outcome was higher for the 2014 ESC algorithm (0.76, 95% CI 0.68–0.84) compared with the 2008 ESC algorithm (0.65, 95% CI 0.56–0.73) and highest for the modified FAST score (0.82, 95% CI 0.75–0.89). Patients classified as intermediate-high-risk by the 2014 ESC algorithm had a 8.9-fold increased risk for an adverse outcome (3.2–24.2, p<0.001 compared with intermediate-low- and low-risk patients), while the highest OR was observed for a modified FAST score ≥3 points (OR 15.9, 95% CI 5.3–47.6, p<0.001).The 2014 ESC algorithm improves risk stratification of not-high-risk pulmonary embolism compared with the 2008 ESC algorithm. All scores and algorithms accurately identified low-risk patients, while the modified FAST score appears more suitable to identify intermediate-high-risk patients.

scholarly journals Risk stratification of normotensive pulmonary embolism: prognostic impact of copeptin

2015 ◽  
Vol 46 (6) ◽  
pp. 1701-1710 ◽  
Author(s):  
Kristian Hellenkamp ◽  
Johanna Schwung ◽  
Heidi Rossmann ◽  
Anja Kaeberich ◽  
Rolf Wachter ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Adverse Outcome ◽  
Troponin T ◽  
High Sensitivity ◽  
High Risk Group ◽  
Low Risk ◽  
Prognostic Impact ◽  
Increased Risk

The prognostic value of copeptin, the C-terminal fragment of the precursor protein of vasopressin which is released upon stress, and hypotension in pulmonary embolism is unknown, especially if combined with biomarkers reflecting different pathophysiological axes such as myocardial injury (high-sensitivity troponin T (hsTnT)) and stretch (N-terminal pro-brain natriuretic peptide (NT-proBNP)).We prospectively studied 268 normotensive pulmonary embolism patients included in a single-centre cohort study.Patients with an adverse 30-day outcome (5.6%) had higher copeptin levels than patients with a favourable course (median (interquartile range) 51.8 (21.6–90.8) versus 13.2 (5.9–39.3) pmol·L−1; p=0.020). Patients with copeptin levels above the calculated optimal cut-off value of 24 pmol·L−1 had a 5.4-fold increased risk for an adverse outcome (95% CI 1.68–17.58; p=0.005). We developed a strategy for risk stratification based on biomarkers. None of 141 patients (52.6%) with hsTnT <14 pg·mL−1 or NT-proBNP <600 pg·mL−1 had an adverse outcome (low risk). Copeptin ≥24 pmol·L−1 stratified patients with elevated hsTnT and NT-proBNP as intermediate–low and intermediate–high risk (5.6% and 20.0% adverse outcome, respectively). Compared to the algorithm proposed by the 2014 European Society of Cardiology guideline, more patients were classified as low risk (52.8% versus 17.5%, p<0.001) and more patients in the intermediate–high risk group had an adverse outcome (20.0% versus 11.6%).Copeptin might be helpful for risk stratification of normotensive patients with pulmonary embolism, especially if integrated into a biomarker-based algorithm.

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