Assessment of Renal Dysfunction Improves the Simplified Pulmonary Embolism Severity Index (sPESI) for Risk Stratification in Patients with Acute Pulmonary Embolism

Background: Whereas the major strength of the simplified pulmonary embolism severity index (sPESI) lies in ruling out an adverse outcome in patients with sPESI of 0, the accuracy of sPESI ≥ 1 in risk assessment remains questionable. In acute pulmonary embolism (APE), the estimated glomerular filtration rate (eGFR) can be viewed as an integrate marker reflecting not only previous chronic kidney disease (CKD) damage but also comorbid conditions and hemodynamic disturbances associated with APE. We sought to determine whether renal dysfunction assessment by eGFR improves the sPESI score risk stratification in patients with APE. Methods: 678 consecutive patients with APE were prospectively enrolled. Renal dysfunction (RD) at diagnosis of APE was defined by eGFR < 60 mL/min/1.73 m2 and acute kidney injury (AKI) by elevation of creatinine level >25% during in-hospital stay. Results: RD was observed in 26.9% of the cohort. AKI occurred in 18.8%. A stepwise increase in 30-day mortality, cardiovascular mortality and overall mortality was evident with declining renal function. Multivariate analysis identified RD and CRP (C-reactive protein) level but not sPESI score as independent predictors of 30-day mortality. AKI, 30-day mortality, overall mortality, and cardiovascular mortality were at their highest level in patients with eGFR < 60 mL/min/1.73 m2 and sPESI ≥1. Conclusion: in patients with APE, the addition of RD to the sPESI score identifies a specific subset of patients at very high mortality.

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Trends in risk stratification, in-hospital management and mortality of patients with acute pulmonary embolism: an analysis from China pUlmonary thromboembolism REgistry Study (CURES)

European Respiratory Journal ◽

10.1183/13993003.02963-2020 ◽

2021 ◽

pp. 2002963

Author(s):

Zhenguo Zhai ◽

Dingyi Wang ◽

Jieping Lei ◽

Yuanhua Yang ◽

Xiaomao Xu ◽

...

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Hospital Mortality ◽

Acute Pulmonary Embolism ◽

Severity Index ◽

Disease Diagnosis ◽

Initial Therapy ◽

European Respiratory Society ◽

Systemic Thrombolysis ◽

All Cause Mortality

BackgroundSimilar trends of management and in-hospital mortality of acute pulmonary embolism (PE) have been reported in European and American populations. However, these tendencies were not clear in Asian countries.ObjectivesWe retrospectively analyzed the trends of risk stratification, management and in-hospital mortality for patients with acute PE through a multicenter registry in China (CURES).MethodsAdult patients with acute symptomatic PE were included between 2009 and 2015. Trends in disease diagnosis, treatment and death in hospital were fully analyzed. Risk stratification was retrospectively classified by hemodynamical status and the simplified Pulmonary Embolism Severity Index (sPESI) score according to the 2014 European Society of Cardiology/European Respiratory Society guidelines.ResultsAmong overall 7438 patients, the proportions with high (hemodynamically instability), intermediate (sPESI≥1) and low (sPESI=0) risk were 4.2%, 67.1% and 28.7%, respectively. Computed tomographic pulmonary angiography was the widely employed diagnostic approach (87.6%) and anticoagulation was the frequently adopted initial therapy (83.7%). Between 2009 and 2015, a significant decline was observed for all-cause mortality (from 3.1% to 1.3%, adjusted Pfor trend=0.0003), with a concomitant reduction in use of initial systemic thrombolysis (from 14.8% to 5.0%, Pfor trend<0.0001). The common predictors for all-cause mortality shared by hemodynamically stable and unstable patients were co-existing cancer, older age, and impaired renal function.ConclusionsThe considerable reduction of mortality over years was accompanied by changes of initial treatment. These findings highlight the importance of risk stratification-guided management throughout the nation.

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Risk Stratification of Patients with Acute Pulmonary Embolism using the Pulmonary Embolism Severity Index Score from the Emergency Medicine Pulmonary Embolism in the Real World Registry (EMPEROR)

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2009.06.023 ◽

2009 ◽

Vol 37 (2) ◽

pp. 218 ◽

Cited By ~ 2

Author(s):

D. Schreiber ◽

J.L. Fansler ◽

B. Briese ◽

B. Hiestand ◽

D. Slattery ◽

...

Keyword(s):

Emergency Medicine ◽

Pulmonary Embolism ◽

Risk Stratification ◽

Real World ◽

Acute Pulmonary Embolism ◽

Severity Index ◽

Index Score ◽

The Real ◽

Severity Index Score

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d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029618776799 ◽

2018 ◽

Vol 24 (8) ◽

pp. 1340-1346 ◽

Cited By ~ 2

Author(s):

Marta Kozlowska ◽

Magdalena Plywaczewska ◽

Marcin Koc ◽

Szymon Pacho ◽

Anna Wyzgal ◽

...

Keyword(s):

Pulmonary Embolism ◽

Adverse Event ◽

Risk Stratification ◽

Prognostic Value ◽

Acute Pulmonary Embolism ◽

Clinical Course ◽

Area Under The Curve ◽

Severity Index ◽

Net Reclassification Improvement ◽

D Dimer

d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.

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Stroke and refractory hypoxaemia: complications of pulmonary embolism

BMJ Case Reports ◽

10.1136/bcr-2021-244284 ◽

2021 ◽

Vol 14 (9) ◽

pp. e244284

Author(s):

Mafalda Sá Pereira ◽

Rita Homem ◽

Tiago Judas ◽

Francisca Delerue

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Mortality Risk ◽

Cardiovascular Mortality ◽

Patent Foramen Ovale ◽

Acute Pulmonary Embolism ◽

Multidisciplinary Approach ◽

Foramen Ovale ◽

History Of Surgery ◽

History Of

Acute pulmonary embolism is one of the main causes of cardiovascular mortality. Treatment should be guided according to mortality risk stratification, but an individualised and multidisciplinary approach is often required. Concomitant persistent hypoxaemia can be present in cases of intracardiac shunt. In this report, we describe a 46-year-old woman with a history of surgery, presenting with pulmonary embolism with refractory hypoxaemia and simultaneous ischaemic stroke. Fibrinolysis was successfully performed, and the patient made a full recovery. Additional investigations identified a patent foramen ovale, which was later closed. She had no recurrent thrombotic events.

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Red cell distribution width in acute pulmonary embolism patients: A simple aid for improvement of the 30-day mortality risk stratification based on the pulmonary embolism severity index

Heart & Lung ◽

10.1016/j.hrtlng.2019.02.006 ◽

2019 ◽

Vol 48 (5) ◽

pp. 436-445 ◽

Cited By ~ 2

Author(s):

Ivana Jurin ◽

Vladimir Trkulja ◽

Marko Ajduk ◽

Tomislav Letilović ◽

Irzal Hadžibegović

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Mortality Risk ◽

Acute Pulmonary Embolism ◽

Severity Index ◽

Red Cell Distribution Width ◽

Red Cell ◽

Cell Distribution ◽

Distribution Width

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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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