Risk stratification of patients with pulmonary embolism based on pulse rate and D-dimer concentration

Summary

To enable outpatient treatment of a selected group of patients with pulmonary embolism (PE), insight in the determinants of adverse clinical outcome is warranted. We have identified risk factors for serious adverse events (SAE) within the first 10 days of acute PE. We have retrospectively analysed data of 440 consecutive patients with acute PE. Collected data included age, gender, medical history, blood pressure, pulse rate and D-dimer concentration. The variables associated with SAE in the first 10 days in univariate analysis (p<0.15) have been included in a multivariate logistic regression model (backward conditional, p out>0.10). In 440 patients with acute PE, 20 SAEs occurred in a 10-day follow-up period. Pulse rate ≥100 beats per minute (bpm) (OR, 6.85; 95%CI 1.43–32.81) and D-dimer concentration ≥3,000 µg/ml (OR, 5.51; 95%CI 0.68–44.64) were significantly related to the SAEs. All SAEs were predicted by a pulse rate ≥100 bpm and/or a D-dimer concentration ≥3,000 µg/ml. Older age, gender, history of venous thromboembolism (VTE), heart failure, chronic obstructive pulmonary disease, cancer or a systolic blood pressure < 90 mm Hg had no significant influence on short term SAEs. Pulse rate and D-dimer concentration can be used to identify patients with acute PE, who are at risk for adverse clinical outcome during the first 10 days of hospitalisation. Outpatient treatment of PE-patients with a pulse rate ≥100 bpm and/or a D-dimer concentration ≥3,000 µg/ml has to be discouraged.

Keywords

Pulmonary embolism - serious adverse events - risk - prediction model - outcome

• References

• 1 Goldhaber SZ, Elliott CG. Acute pulmonary embolism: Part II Risk stratification, treatment and prevention. Circulation 2003; 108: 2834-2838.
• 2 Tapson VF, Witty LA. Massive pulmonary embolism: diagnostic and therapeutic strategies. Clin Chest Med 1995; 16: 329-340.
• 3 Buller HR, Agnelli G, Hull RD. et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 401S-28S.
• 4 Wells PS, Kovacs MJ, Bormanis J. et al. Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin: a comparison of patient self-injection with homecare injection. Arch Intern Med 1998; 158: 1809-1812.
• 5 Kovacs MJ, Anderson D, Morrow B. et al. Outpatient treatment of pulmonary embolism with dalteparin. Thromb Haemost 2000; 83: 209-211.
• 6 Wells PS, Anderson DR, Rodger MA. et al. A randomized trial comparing 2 low-molecular-weight heparins for the outpatient treatment of deep venous thrombosis and pulmonary embolism. Arch Intern Med 2005; 165: 733-738.
• 7 Aujesky D, Smith KJ, Cornuz J. et al. Cost-effectiveness of low-molecular-weight heparin for treatment of pulmonary embolism. Chest 2005; 128: 1601-1610.
• 8 Aujesky D, Obrosky DS, Stone RA. et al. A prediction rule to identify low-risk patients with pulmonary embolism. Arch Intern Med 2006; 166: 169-175.
• 9 Wicki J, Perrier A, Perneger TV. et al. Predicting adverse outcome in patients with acute pulmonary embolism: A risk score. Thromb Haemost 2000; 84: 548-552.
• 10 Klok FA, Djurabi RK, Nijkeuter M. et al. High D-dimer level is associated with increased 15-d and 3 months mortality through a more central localization of pulmonary emboli and serious comorbidity. Br J Haematol 2008; 140: 218-222.
• 11 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386-1389.
• 12 Laporte S, Mismetti P, Décousus H. et al. Clinical Predictors for fatal pulmonary embolism in 15520 patients with venous thromboembolism. Circulation 2008; 117: 1711-1716.
• 13 Nijkeuter M, Söhne M, Tick LW. et al. The natural course of hemodynamically stable pulmonary embolism. Clinical outcome and risk factors in a large prospective cohort study. Chest 2007; 131: 517-523.
• 14 Nendaz MR, Bandelier P, Aujesky D. et al. Validation of a risk score identifying patients with acute pulmonary embolism, who are at low risk of clinical adverse outcome. Thromb Haemost 2004; 91: 1232-1236.
• 15 Konstantinides S, Geibel A, Olschewski M. et al. Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism. Results of a multicenter registry. Circulation 1997; 96: 882-888.
• 16 The Columbus Investigators. Low-molecularweight heparin in the treatment of patients with venous tromboembolism. N Engl J Med. 1997 337. 657-662.
• 17 Simonneau G, Sors H, Charbonnier B. et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. N Engl J Med 1997; 337: 663-669.
• 18 Caprini JA, Tapson VF, Hyers TM. et al. Treatment of venous tromboembolism: Adherence to guidelines and impact of physician knowledge, attitudes, and beliefs. J Vasc Surg 2005; 42: 726-733.
• 19 Panis LJ, Kolbach DN, Hamulyák K. et al. Identifying inappropriate hospital stay in patients with venous thromboembolism. Eur J Intern Med 2004; 15: 39-44.
• 20 van der Meer RW, Pattynama PM, van Strijen MJ. et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology 2005; 235: 798-803.
• 21 Goldhaber SZ. Assessing the prognosis of acute pulmonary embolism: Tricks of the trade. Chest 2008; 133: 334-336.
• 22 Aujesky D, Roy PM, Guy M. et al. Prognostic value of D-dimer in patients with pulmonary embolism. Thromb Haemost 2006; 96: 478-482.
• 23 Paneesha S, Cheyne E, French K. et al. High D-dimer levels at presentation in patients with venous thromboembolism is a marker of adverse clinical outcome. Br J Haematol 2006; 135: 85-90.
• 24 Schutgens REG, Beckers MMJ, Haas JLM. et al. The predictive value of D-dimer measurement for cancer in patients with deep vein thrombosis. Haematologica 2005; 90: 214-219.
• 25 Gaffney PJ, Creighton LJ, Callus MJ. et al. Monoclonal antibodies to crosslinked fibrin degradation products (XL-FDP). II Evolution in a variety of clinical conditions. Br J Haematol 1988; 68: 91-96.
• 26 Schutgens REG, Haas FJ, Biesma DH. Reduced efficacy of clinical probability score and D-dimer assay in eldery subjects suspecting of having deep vein thrombosis. Br J Haematol 2005; 129: 653-657.