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DOI: 10.1160/TH10-09-0577
Association between the Pulmonary Embolism Severity Index (PESI) and short-term clinical deterioration
Publication History
Received:
14 September 2010
Accepted after major revision:
10 January 2010
Publication Date:
28 November 2017 (online)
Summary
The Pulmonary Embolism Severity Index (PESI) has been shown to predict 30 and 90 day mortality after PE. However, whether the PESI predicts patients who will be free of clinically adverse outcomes during a typical hospitalisation is not known. Retrospective analysis of Emergency Department patients with PE from May 2006 to April 2008. We compiled demographics, data to calculate the PESI and a composite outcome. Patients were considered to have a negative PESI if they were in category I or II (≤85 points). Patients were considered to have the composite outcome if, within five days of diagnosis, they: A) had recurrent PE; B) developed a new cardiac dysrhythmia; C) required advanced cardiac life support; D) required respiratory support; E) required vasopressors; F) received thrombolysis; G) had major bleeding; H) returned to the ED; I) died. We enrolled 245 patients with PE. Of these, 115 (47%) were male, 204 (83%) were white. The mean age was 57 ± 17 years. The PESI identified 109 (44%) as low risk and 136 (56%) as high risk. Sixty-one (26%) patients had the outcome, of whom nine (14%) were char-acterised as low risk by the PESI. Test characteristics were: sensitivity 86% (95% confidence interval [CI]: 75%-93%), specificity 55% (95% CI: 47%-62%), NPV 63% (95% CI: 55%-70%), PPV 40% (95% CI: 31%-49%), LR(+) 1.9 (95% CI: 1.57–2.30) and LR(-) 0.26 (95% CI: 0.14–0.48). Of the patients categorised by the PESI as safe for discharge, 14% had an adverse clinical event or required a hospital-based intervention within the first five days after PE diagnosis. Improvements in the risk stratification of patients with PE are still needed.
* Presented at the American College of Emergency Physicians, Scientific Assembly, Boston, 2009.
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References
- 1 Kasper W, Konstantinides S, Geibel A. et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997; 30: 1165-1171.
- 2 Courtney DM, Kline JA. Prospective use of a clinical decision rule to identify pulmonary embolism as likely cause of outpatient cardiac arrest. Resuscitation 2005; 65: 57-64.
- 3 White RH. The epidemiology of venous thromboembolism. Circulation 2003; 107: I4-8.
- 4 Kovacs MJ, Anderson D, Morrow B. et al. Outpatient treatment of pulmonary embolism with dalteparin. Thromb Haemost 2000; 83: 209-211.
- 5 Almahameed A, Carman TL. Outpatient management of stable acute pulmonary embolism: proposed accelerated pathway for risk stratification. Am J Med 2007; 120: S18-25.
- 6 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.
- 7 Aujesky D, Mazzolai L, Hugli O. et al. Outpatient treatment of pulmonary embolism. Swiss Med Wkly 2009; 139: 685-690.
- 8 Aujesky D, Obrosky DS, Stone RA. et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005; 172: 1041-1046.
- 9 Fraga M, Taffe P, Mean M. et al. The inter-rater reliability of the Pulmonary Embolism Severity Index. Thromb Haemost 2010; 104: 1258-1262.
- 10 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.
- 11 Jimenez D, Yusen RD, Otero R. et al. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. Chest 2007; 132: 24-30.
- 12 Donze J, Le Gal G, Fine MJ. et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism. Thromb Haemost 2008; 100: 943-948.
- 13 Chan CM, Woods C, Shorr AF. The validation and reproducibility of the pulmonary embolism severity index. J Thromb Haemost 8: 1509-1514.
- 14 Kabrhel C, Weston S, Liu S. et al. Outcomes Considered Most Important by Emergency Physicians when Determining Disposition of Patients with Pulmonary Embolism. Int J Emerg Med. 2010 in press.
- 15 The PIOPED Investigators.. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). J Am Med Assoc 1990; 263: 2753-2759.
- 16 Aujesky D, Stone RA, Kim S. et al. Length of hospital stay and postdischarge mortality in patients with pulmonary embolism: a statewide perspective. Arch Intern Med 2008; 168: 706-712.
- 17 Jones SR, Carley S, Harrison M. An introduction to power and sample size estimation. Emerg Med J 2003; 20: 453-458.
- 18 Jimenez D, Yusen RD. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. Curr Opin Pulm Med 2008; 14: 414-421.
- 19 Nordenholz K, Ryan J, Atwood B, Heard K. Pulmonary embolism risk stratification: Pulse oximetry and pulmonary embolism severity index. J Emerg Med. 2009 preprint online.
- 20 Fremont B, Pacouret G, Jacobi D. et al. Prognostic value of echocardiographic right/left ventricular end-diastolic diameter ratio in patients with acute pulmonary embolism: results from a monocenter registry of 1,416 patients. Chest 2008; 133: 358-362.
- 21 Ghuysen A, Ghaye B, Willems V. et al. Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism. Thorax 2005; 60: 956-961.
- 22 Sohne M, Ten Wolde M, Boomsma F. et al. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost 2006; 4: 552-556.
- 23 Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 2007; 116: 427-433.
- 24 Moores L, Aujesky D, Jimenez D. et al. Pulmonary Embolism Severity Index and troponin testing for the selection of low-risk patients with acute symptomatic pulmonary embolism. J Thromb Haemost 8: 517-522.
- 25 Agterof MJ, van Bladel ER, Schutgens RE. et al. Risk stratification of patients with pulmonary embolism based on pulse rate and D-dimer concentration. Thromb Haemost 2009; 102: 683-687.
- 26 Kabrhel C, McAfee AT, Goldhaber SZ. The probability of pulmonary embolism is a function of the diagnoses considered most likely before testing. Acad Emerg Med 2006; 13: 471-474.