Effectiveness of prognosticating pulmonary embolism using the ESC algorithm and the Bova score

Summary

The prognostic value of the European Society of Cardiology (ESC) 2014 algorithm and the Bova score has lacked adequate validation. According to the ESC 2014 guidelines and the Bova score, we retrospectively risk stratified normotensive patients with PE who were enrolled in the PROTECT study. This study used a complicated course (which consisted of death from any cause, haemodynamic collapse, or recurrent PE) as the primary endpoint, and follow-up occurred through 30 days after the PE diagnosis. Of 848 patients, 37 % had a sPESI of 0 and 5 (1.6 %; 95 % confidence interval [CI], 0.5-3.7 %) experienced a complicated course. Of 143 patients with a sPESI of 0 points and negative computed tomographic pulmonary angiography (CTPA) for right ventricle (RV) dysfunction, three (2.1 %; 95 % CI, 0.4-6.0 %) experienced a complicated course. Four hundred seventy-eight (56 %) patients with a sPESI ≥ 1 had echocardiographic evidence of RV dysfunction or elevated troponin level or none, and 48 (10 %, 95 % CI, 7.5-13.1 %) experienced a complicated course. Fifty-seven (6.7 %) patients with a sPESI ≥ 1 had echocardiographic RV dysfunction and elevated troponin level, and 10 (17.5 %; 95 % CI, 8.8-29.9 %) experienced a complicated course, compared to 21.6 % (8 of 37 patients, 21.6 %; 95 % CI, 9.8-38.2 %) in Bova risk class III. In conclusion, the ESC 2014 prognostic algorithm is effective in the risk stratification of normotensive patients with PE. Use of CTPA did not improve the ability for identification of low-risk PE. Bova risk scoring did not significantly improve identification of intermediate-high risk PE.

Jiménez et al. Validation of the ESC 2014 prognostication algorithm

Keywords

Pulmonary embolism - prognosis - clinical scores - biomarkers - echo-cardiography

^* The PROTECT investigators are listed in the Appendix.

• References

• 1 Laporte S, Mismetti P, Décousus H. et al. Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry. Circulation 2008; 117: 1711-1716.
• 2 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.
• 3 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.
• 4 Aujesky D, Roy PM, Verschuren F. et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378: 41-48.
• 5 Jiménez D, Aujesky D, Yusen RD. Risk stratification of normotensive patients with acute symptomatic pulmonary embolism. Br J Haematol 2010; 151: 415-424.
• 6 Jiménez D, Aujesky D, Moores L. et al. Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism. Thorax 2011; 66: 75-81.
• 7 Jimenez D, Kopecna D, Tapson V. et al. Derivation and validation of multi-marker prognostication for normotensive patients with acute symptomatic pulmonary embolism. Am J Respir Crit Care Med 2014; 189: 718-726.
• 8 Konstantinides SV, Torbicki A, Agnelli G. et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS). Eur Heart J 2014; 35: 3033-3073.
• 9 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.
• 10 Jiménez D, Moores L, Gómez V. et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170: 1383-1389.
• 11 Bova C, Sanchez O, Prandoni P. et al. Identification of intermediate-risk patients with acute symptomatic pulmonary embolism: analysis of individual participants’ data from six studies. Eur Respir J 2014; 44: 694-703.
• 12 Fernandez C, Bova C, Sanchez O. et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism. Chest. 2015 Epub ahead of print.
• 13 Jiménez D, Lobo JL, Monreal M. et al. Prognostic significance of multidetector CT in normotensive patients with pulmonary embolism: results of the protect study. Thorax 2014; 69: 109-115.
• 14 Jiménez D, Lobo JL, Monreal M. et al. Prognostic significance of multidetector computed tomography in normotensive patients with pulmonary embolism: rationale, methodology and reproducibility for the PROTECT study. J Thromb Thrombolysis 2012; 34: 187-192.
• 15 Grifoni S, Olivotto I, Cecchini P. et al. Short term clinical outcome of patients with pulmonary embolism, normal blood pressure and echocardiographic right ventricular dysfunction. Circulation 2000; 101: 2817-2822.
• 16 Sanchez O, Trinquart L, Caille V. et al. Prognostic factors for pulmonary embolism: the PREP study, a prospective multicentre cohort study. Am J Respir Crit Care Med 2010; 181: 168-173.
• 17 Jiménez D, Díaz G, Molina J. et al. Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. Eur Respir J 2008; 31: 847-853.
• 18 Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of haemodynamically significant pulmonary embolism. Chest 2002; 121: 877-905.
• 19 Kasper W, Konstantinides S, Geibel A. et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multi-centre registry. J Am Coll Cardiol 1997; 30: 1165-1171.
• 20 Zondag W, Kooiman J, Klok FA, Dekkers OM, Huisman MV. Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. Eur Respir J 2013; 42: 134-144.
• 21 Chatterjee S, Chakraborty A, Weinberg I. et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial haemorrhage: a meta-analysis. J Am Med Assoc 2014; 311: 2414-2421.
• 22 Zwierzina D, Limacher A, Méan M. et al. Prospective comparison of clinical prognostic scores in elder patients with a pulmonary embolism. J Thromb Haemost 2012; 10: 2270-2276.
• 23 Righini M, Roy PM, Meyer G. et al. The Simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism. J Thromb Haemost 2011; 09: 2115-2117.
• 24 Sam A, Sánchez D, Gómez V. et al. The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism. Eur Respir J 2011; 37: 762-766.
• 25 Zondag W, Mos IC, Creemers-Schild D. et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia study. J Thromb Haemost 2011; 09: 1500-1507.