Derivation and validation of a multivariate model to predict mortality from pulmonary embolism with cancer: The POMPE-C tool

Abstract

Background Clinical guidelines recommend risk stratification of patients with acute pulmonary embolism (PE). Active cancer increases risk of PE and worsens prognosis, but also causes incidental PE that may be discovered during cancer staging. No quantitative decision instrument has been derived specifically for patients with active cancer and PE. Methods Classification and regression technique was used to reduce 25 variables prospectively collected from 408 patients with AC and PE. Selected variables were transformed into a logistic regression model, termed POMPE-C, and compared with the pulmonary embolism severity index (PESI) score to predict the outcome variable of death within 30 days. Validation was performed in an independent sample of 182 patients with active cancer and PE. Results POMPE-C included eight predictors: body mass, heart rate >100, respiratory rate, SaO2%, respiratory distress, altered mental status, do not resuscitate status, and unilateral limb swelling. In the derivation set, the area under the ROC curve for POMPE-C was 0.84 (95% CI: 0.82-0.87), significantly greater than PESI (0.68, 0.60-0.76). In the validation sample, POMPE-C had an AUC of 0.86 (0.78-0.93). No patient with POMPE-C estimate ≤5% died within 30 days (0/50, 0-7%), whereas 10/13 (77%, 46-95%) with POMPE-C estimate >50% died within 30 days. Conclusion In patients with active cancer and PE, POMPE-C demonstrated good prognostic accuracy for 30 day mortality and better performance than PESI. If validated in a large sample, POMPE-C may provide a quantitative basis to decide treatment options for PE discovered during cancer staging and with advanced cancer.

Symptoms, signs, suspicion and setting: a PESI score for cancer-associated pulmonary embolism?

“…4) Beyond symptoms, the presence of abnormal vital signs (such as systolic blood pressure <100 mmHg, heart rate >100 beats per minute and oxygen saturation <95%) predicted an increased risk of short-term mortality. Previous studies have arrived at the same conclusion [7,8], suggesting that these clinical signs are the "red flags" to watch out for when managing a patient with cancer-associated PE.…”

“…Third, the advantage of a three-group classification is unclear to us when the authors actually clearly showed that only the TA-UPE group had its distinct (low) mortality profile. This criticism, however, should not conceal that the current study is, among other previous work on this issue [7,8,22], a stringent attempt to classify cancer-associated PE. Regarding antithrombotic therapy, two end-points are of interest, namely recurrent VTE and major bleeding [9].…”

“…Finally, guideline-endorsed risk assessment models that inform whether patients with PE should be hospitalised or may be treated as outpatients, such as the (simplified) Pulmonary Embolism Severity Index ((s)PESI) [13,14], have limited utility for cancer patients, because they innately classify cancer patients in the "not low-risk" categories [15] or even fail to predict short-term mortality at all [16]. Therefore, cancer-specific PE risk tools have been developed [7,8], but they do not account for UPE. Thus, contemporary clinical data that could fill this evidence gap are much needed to identify patients with cancer-associated PE who can safely be treated as outpatients [17,18].…”

Immediate Discharge and Home Treatment With Rivaroxaban of Low‐risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One‐year Preplanned Analysis

“…8 Patients with active malignancy were further risk stratified using the POMPE-C tool (Table 2). 12 Clinicians completed a survey (REDCap; see Data Supplement S1, available as supporting information in the online version of this paper) in real time that required all components of Hestia to be satisfied and initiated a standardized order set including complete blood count, a basic metabolic panel, optionally 1 mg/ kg enoxaparin, and one 15-mg rivaroxaban dose by mouth, prior to discharge. We had two reasons for administering the single dose of enoxaparin in addition to rivaroxaban at diagnosis.…”

Cost of Treating Venous Thromboembolism With Heparin and Warfarin Versus Home Treatment With Rivaroxaban

“…While DVT has been treated as an outpatient for many years, recently developed risk stratification tools have been validated to select patients with PE who have a low risk of shortterm complications. [1][2][3][4][5][6][7] In particular, the Hestia criteria identifies a subgroup of PE patients who have a 1.0% mortality rate as outpatients over 3 months and a low rate of short-term complications requiring rehospitalization. 8 In this article, we assumed that many patients with DVT have undiagnosed PE and therefore must undergo the same risk stratification as patients with documented PE.…”