Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis

Becattini, Cecilia; Maraziti, Giorgio; Vinson, David R.; Ng, A.; Exter, Paul L. den; Côté, Benoît; Vanni, Simone; Doukky, Rami; Khemasuwan, Danai; Weekes, Anthony J.; Soares, Thiago Horta; Özsu, Savaş; Friz, Hernan Polo; Erol, Serhat; Agnelli, Giancarlo; Jiménez, David

doi:10.1093/eurheartj/ehab329

Cited by 50 publications

(42 citation statements)

References 56 publications

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“…We conducted a rigorous statistical analysis and stringent vetting of RV assessments among other important candidate variables. We think our findings add to recent meta‐analyses of low risk PE by contemporaneously evaluating the variable prognostic importance of abnlRV measurements for predicting CD within 5 and 30 days 19,21 . GDE score was the top predictor of CD overall ( Figure 1 ) .…”

Section: Discussionsupporting

confidence: 53%

“…We think our findings add to recent meta-analyses of low risk PE by contemporaneously evaluating the variable prognostic importance of abnlRV measurements for predicting CD within 5 and 30 days. 19,21 GDE score was the top predictor of CD overall (Figure 1). This comparison allows clinicians to better understand the frequent clinical scenario of discordant RV assessment findings.…”

Section: Discussionmentioning

confidence: 99%

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Can right ventricular assessments improve triaging of low risk pulmonary embolism?

Raper

Thomas

Lupez

et al. 2022

Academic Emergency Medicine

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Objectives Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the Simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to (1) determine if RV assessment variables add prognostic accuracy for 5‐day clinical deterioration in patients classified low risk by sPESI, and (2) determine the prognostic importance of RV assessments compared to other variables and to each other. Methods We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed, and compared prognostic accuracy of, full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE. Results Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by CT, 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77–0.82) and 0.71 (0.68–0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5‐day clinical deterioration by the multivariable logistic regression. Conclusions A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5‐day clinical deterioration versus one without.

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Section: Discussionsupporting

confidence: 53%

Section: Discussionmentioning

confidence: 99%

Can right ventricular assessments improve triaging of low risk pulmonary embolism?

Raper

Thomas

Lupez

et al. 2022

Academic Emergency Medicine

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“…In einer Metaanalyse, basierend auf 22 Studien an insgesamt 3295 Patienten mit „niedrigem“ klinischen Risiko hatten jene mit RV-Dysfunktion in der Bildgebung (Echokardiographie oder CTPA) ein 4,2-fach erhöhtes Risiko, innerhalb der ersten 30 Tage zu versterben [ 18 ]. Diese Ergebnisse wurden kürzlich von einer weiteren Metaanalyse individueller Patientendaten aus den oben genannten Studien bestätigt [ 19 ] und unterstützen nachdrücklich die Leitlinienempfehlung zur Evaluation der Herzmorphologie und -funktion unabhängig von den klinischen Symptomen und Zeichen bei Aufnahme. Dies dürfte in der Ära der bettseitigen „point-of-care“-fokussierten Ultraschalluntersuchung [ 20 ] in Notaufnahme- und Intensivstationen keine logistische Herausforderung mehr darstellen.…”

Section: Risikostratifizierungunclassified

Diagnostik und Therapie der Lungenembolie

Konstantinides

Mavromanoli

Hobohm

2021

Herz

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“…Identification of patients at low risk of death can be made by clinical models or exclusion of right ventricle dysfunction [9-11, 19, 20]. Recently, a prognostic role of right ventricle assessment has been confirmed also in PE patients at low-risk according to clinical models [21]. In patients with acute PE and low risk for death, out-patient management (hospitalization < 48 h) has shown safe in clinical studies [22][23][24]; however, the feasibility of out-patient management in clinical practice is debated.…”

Section: Discussionmentioning

confidence: 99%

Contemporary clinical management of acute pulmonary embolism: the COPE study

et al. 2022

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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.

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Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis

Cited by 50 publications

References 56 publications

Can right ventricular assessments improve triaging of low risk pulmonary embolism?

Can right ventricular assessments improve triaging of low risk pulmonary embolism?

Diagnostik und Therapie der Lungenembolie

Contemporary clinical management of acute pulmonary embolism: the COPE study

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