Chest
Volume 141, Issue 4, April 2012, Pages 916-922
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Original Research
Pulmonary Vascular Disease
A Strategy Combining Imaging and Laboratory Biomarkers in Comparison With a Simplified Clinical Score for Risk Stratification of Patients With Acute Pulmonary Embolism

https://doi.org/10.1378/chest.11-1355Get rights and content

Background

This study aimed to assess the performance of two prognostic models—the European Society of Cardiology (ESC) model and the simplified Pulmonary Embolism Severity Index (sPESI)—in predicting short-term mortality in patients with pulmonary embolism (PE).

Methods

We compared the test characteristics of the ESC model and the sPESI for predicting 30-day outcomes in a cohort of 526 patients with objectively confirmed PE. The primary end point of the study was all-cause mortality. The secondary end point included all-cause mortality, nonfatal symptomatic recurrent VTE, or nonfatal major bleeding.

Results

Overall, 40 of 526 patients died (7.6%; 95% CI, 5.3%–9.9%) during the first month of follow-up. The sPESI classified fewer patients as low risk (31% [165 of 526], 95% CI, 27%–35%) compared with the ESC model (39% [207 of 526], 95% CI, 35% to 44%; P < .01). Importantly however, low-risk patients based on the sPESI had no 30-day mortality compared with 3.4% (95% CI, 0.9-5.8) in low-risk patients by the ESC model. The secondary end point occurred in 1.8% of patients in the sPESI low-risk and 5.8% in the ESC low-risk group (difference, 4.0 percentage points; 95% CI, 0.2-7.8). The prognostic ability of the ESC model remained significant in the subgroup of patients at high-risk according to the sPESI model (OR 1.95, 95% CI, 1.41 to 2.71, P < .001).

Conclusions

Both the sPESI and the ESC model successfully predict 30-day mortality after acute symptomatic PE, but exclusion of an adverse early outcome does not appear to require routine imaging procedures or laboratory biomarker testing.

Section snippets

Study Design

Using prospectively collected baseline data at the time of PE diagnosis and outcome data from the same cohort, we assessed the test characteristics of the simplified PESI and the ESC prognostic score for predicting 30-day mortality, nonfatal recurrent VTE, and nonfatal major bleeding. We then assessed the ability of both prediction rules to identify low-risk patients with acute PE who could be candidates for treatment in the outpatient setting. All patients provided informed consent for their

Results

We screened 628 consecutive patients with acute PE for eligibility. The study excluded 21 patients due to lack of troponin testing within 12 h after the diagnosis of PE. Other reasons for exclusion were a technically inadequate or unavailable transthoracic echocardiogram (n = 54), loss to follow-up (n = 15), and refusal to give informed consent (n = 19). Some patients had multiple reasons for exclusion. A total of 526 patients (227 men and 299 women; 85% of the screened population) were

Discussion

Our study validated the recently proposed ESC “instrumental” model (which focuses on biomarkers and imaging findings of RV dysfunction and failure) for risk-stratifying patients with acute symptomatic PE and compared it with the sPESI, a score based on baseline clinical findings and comorbidity. Both the sPESI and the ESC model successfully predicted 30-day mortality after acute symptomatic PE, but an adverse early outcome could safely be excluded using the sPESI alone, without requiring

Acknowledgments

Author contributions: Dr Lankeit: contributed to study concept and design, acquisition of data, analysis and interpretation of data, statistical analysis, critical revision of the manuscript for important intellectual content, and drafting of the manuscript.

Dr Gómez: contributed to study concept and design, acquisition of data, analysis and interpretation of data, statistical analysis, critical revision of the manuscript for important intellectual content, and drafting of the manuscript.

Dr

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    Drs Lankeit and Gómez contributed equally to the manuscript.

    Funding/Support: This work has been supported in part by Instituto de Salud Carlos III [FIS 08/0200], Sociedad Española de Neumología y Cirugía Torácica [SEPAR 2008], and NEUMOMADRID 2010.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

    *

    A complete list of participants is located in e-Appendix 1.

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