Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis

Elias, Antoine; Mallett, Susan; Daoud-Elias, Marie; Poggi, Jean-Noël; Clarke, Mike

doi:10.1136/bmjopen-2015-010324

Cited by 168 publications

(136 citation statements)

References 148 publications

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“…The three most sensitive CPS are the PESI, sPESI and ESC guideline risk stratification criteria, with sensitivities of 0.89, 0.92 and 0.88, respectively, with the sPESI (Table ) as the most validated . A sPESI score = 0 (‘low risk’) has a reported 30‐day mortality rate of 1.0–1.5%, while a score ≥1 (‘high risk’) is 10.7–10.9%, but can be over 20% in haemodynamically unstable patients . When determining from low‐ to intermediate‐risk patients, the sPESI score alone appears superior to other markers of right heart dysfunction (i.e.…”

Section: Predicting Prognosis and Stratification For Managementmentioning

confidence: 99%

“…5,45,46 A sPESI score = 0 ('low risk') has a reported 30-day mortality rate of 1.0-1.5%, while a score ≥1 ('high risk') is 10.7-10.9%, but can be over 20% in haemodynamically unstable patients. 9,47,48 When determining from low-to intermediate-risk patients, the sPESI score alone appears superior to other markers of right heart dysfunction (i.e. cardiac troponin, 49 CTPA and electrocardiography (ECG) 5,17,18 ).…”

Section: Intermediate and High-risk Patientsmentioning

confidence: 99%

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Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

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An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation‐perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50–75 per 100 000 in Australia and New Zealand, with 30‐day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision‐making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation‐perfusion scans) is still necessary for objective diagnosis. Anti‐coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti‐coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti‐coagulation and review. However, treatment should be case dependent with full consideration of the patient’s clinical state. Direct oral anti‐coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti‐coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6–12 months.

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Section: Predicting Prognosis and Stratification For Managementmentioning

confidence: 99%

Section: Intermediate and High-risk Patientsmentioning

confidence: 99%

Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

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“…Several studies showed that more than 50% of patients with acute PE are hemodynamically stable at presentation and are not at low risk of death according to clinical models . In these ‘intermediate‐risk’ patients, several predictors for death have been identified but their clinical value and their optimal use (alone or in combination) are debated .…”

Section: Resultsmentioning

confidence: 99%

Oxygen saturation or respiratory rate to improve risk stratification in hemodynamically stable patients with acute pulmonary embolism

Becattini

Vedovati

Pruszczyk

et al. 2018

Journal of Thrombosis and Haemostasis

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To cite this article: Becattini C, Vedovati MC, Pruszczyk P, Vanni S, Cotugno M, Cimini LA, Stefanone V, de Natale MG, Kozlowska M, Mannucci F, Guirado Torrecillas L, Agnelli G. Oxygen saturation or respiratory rate to improve risk stratification in hemodynamically stable patients with acute pulmonary embolism. J Thromb Haemost 2018; 16: 2397-402. Essentials• In acute pulmonary embolism (PE), risk stratification is essential to drive clinical management. • Improving the 2014-ESC risk stratification strategy is crucial in hemodynamically stable patients. • Oxygen saturation and respiratory rate improve risk stratification in hemodynamically stable PE. • Simple and routine tests improve risk stratification of hemodynamically stable PE. Summary. Background: In patients with acute pulmonary embolism (PE), risk stratification for short-term death is recommended to drive clinical management. A risk stratification strategy combining the simplified Pulmonary Embolism Severity Index (PESI), echocardiography and troponin was proposed by the European Society of Cardiology (ESC) in 2014. The identification of hemodynamically stable patients at increased risk of death by this strategy needs improvement. Objective: To assess whether further stratification by serial cut-off values of oxygen saturation or respiratory rate improves the accuracy of the ESC risk stratification strategy in hemodynamically stable PE patients. Methods: Prospective cohorts of hemodynamically stable patients with PE were merged in a collaborative database. The accuracy of risk stratification for 30-day mortality by the original and a modified 2014 ESC strategy was assessed. Results: Overall, 255 patients (27%) were categorized as low, 510 (54%) as intermediate-low and 181 (19%) as intermediate-high risk according to the original 2014 ESC strategy. Thirty-day mortality was 1.2% in low, 10% in intermediate-low and 11% in intermediate-high-risk patients. By adding oxygen saturation in air of < 88%, the discriminatory power of the 2014 ESC model improved for 30-day mortality (c-statistics, 0.71; 95% confidence interval [CI], 0.65-0.77 vs. 0.63, 95% CI, 0.56-0.69) and for PE-related death (c-statistics, 0.75; 95% CI, 0.69-0.81 vs. 0.63, 95% CI 0.56-0.69). Conclusions: Simple and routine tests, such as oxygen saturation or respiratory rate, could be added to the 2014 ESC strategy for risk stratification to identify hemodynamically stable PE patients at increased risk of death who are potentially candidates for more aggressive treatment.

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“…1,2 There are several risk stratification models for this purpose. 3,4 PESI and sPESI were initially designed and validated for the prediction of short-term mortality, but recent studies have revealed that PESI or sPESI can accurately select patients eligible for outpatient treatment. 3,4 PESI and sPESI were initially designed and validated for the prediction of short-term mortality, but recent studies have revealed that PESI or sPESI can accurately select patients eligible for outpatient treatment.…”

Section: Introductionmentioning

confidence: 99%

“…3,4 The pulmonary embolism severity index (PESI) or simplified version (sPESI) are the most widely validated of these scores with similar accuracy. 3,4 PESI and sPESI were initially designed and validated for the prediction of short-term mortality, but recent studies have revealed that PESI or sPESI can accurately select patients eligible for outpatient treatment. [5][6][7][8][9][10][11] In contrast to PESI, sPESI has six variables with equal points (Table 1).…”

Section: Introductionmentioning

confidence: 99%