Regular ArticleDoes the Pulmonary Embolism Severity Index accurately identify low risk patients eligible for outpatient treatment?☆
Introduction
The mortality and morbidity of pulmonary embolism (PE) may vary considerably depending on the severity of the event and co-morbidities. Predicting patient outcomes may enable different management strategies and may inform the clinician which patients can be treated as outpatients [1], [2].
Over the last decade, several studies have suggested that outpatient treatment in a selected group of hemodynamically stable patients with acute PE is safe [3], [4], [5], [6], [7] . Benefits include: 1) cost savings from a decrease in hospitalizations; 2) fewer patients at risk for hospital acquired infections; and 3) an improvement in quality of life, increased physical activity and social functioning [3], [8], [9], [10], [11]. However, physicians are reluctant to treat patients with PE at home due to uncertainty on how to safely identify patients who are at low risk for short-term adverse events [8], irrespective of whether the adverse events could be averted by hospitalization.
Prognostic models that will accurately predict short-term adverse outcomes may help identify patients with acute PE at low-risk of adverse events that can be safely treated as outpatients. Several prognostic models have been developed to assess the risk of death, recurrent venous thromboembolism (VTE) or major bleeding in patients with acute PE [12]. The most extensively validated prognostic models are the Geneva Prognostic Score (GPS) and the Pulmonary Embolism Severity Index (PESI) [12]. The GPS predicts the combined adverse outcomes of death, recurrent VTE and major bleeding episodes during the first three months following the index PE. However, the GPS prognostic model is not frequently used since it requires the use of ultrasound variables and arterial blood gas which decrease feasibility. Moreover, a comparison of GPS low-risk patients with PESI low-risk patients in a cohort of 599 consecutive patients with acute symptomatic PE showed that the PESI low-risk patients had a significantly lower mortality [13].
The PESI prognostic model stratifies patients in five risk classes with increasing risk of all cause short term mortality without any need for ultrasonography or laboratory studies [14]. The use of the PESI prognostic model requires computation of a score based on 11 variables each with a different weight (Table 1). Recently, a PESI-derived simplified model with a less complex scoring system has been proposed and seems to have a similar prognostic accuracy as the original PESI (Table 1) [15].
We sought to evaluate if the original and the simplified PESI prognostic models could identify patients with acute PE at low risk of short term adverse outcome who can be safely managed as outpatients.
Section snippets
Study population
We performed a retrospective cohort study including consecutive patients with high risk and non-high risk acute PE [16], [17] presenting at the Ottawa Hospital between 1 January 2007 and 31 December 2008 [4]. PE was defined as an intraluminal filling defect on CTPA or a high probability V/Q scan. Patients diagnosed with PE during hospitalization, patients with chronic PE and patients in whom anticoagulation was not initiated (e.g. palliative care patients, small clinical non-significant PE)
Results
A total of 243 patients presenting at the Ottawa Hospital with confirmed PE were included in this study. One hundred and fifteen (47.3%) patients were directly discharged from the Emergency Department and were treated out of the hospital, while 128 (52.7%) patients were admitted. According to the original PESI prognostic model, 118 (48.6%; 95% CI, 42.1 – 55.0) patients were classified as low risk (class I and II) and 125 (51.4%; 95% CI, 45.0 – 58.0) were classified as high risk (class III to
Discussion
The results of our study suggest that both PESI prognostic models accurately identify patients with acute PE who are at low risk for short-term adverse events, including death, recurrent venous thromboembolism and major hemorrhage. None of the low risk patients died or had any adverse event within the first 14 days. Both PESI prognostic models also seem to identify patients with acute PE at low risk of adverse outcome who can be safely managed as outpatients.
Our results are consistent with
Statement of conflict of interest
None declared.
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2021, Thrombosis ResearchCitation Excerpt :In the PEITHO study [19] the 2008 ESC model, classifying PE into intermediate high-risk, was associated with the combined risk of death and haemodynamic deterioration, but not with death alone. The survey is also justified as evidence from studies supports the use of hospital checklists [6–8] as an alternative to prognostic models [9,10] for deciding whether or not a PE patient is suitable for out-of-hospital management. The Hestia checklist allows more than 50% of patients with PE to be discharged early with a low-risk of adverse outcomes [10,20–22] similarly to the risk prediction from prognostic models such as sPESI [10].
Pulmonary Embolism in Patients Hospitalized With COVID-19 (From a New York Health System)
2020, American Journal of CardiologyCitation Excerpt :Compare with the larger Northwell series,10 our cohort had higher rates of ICU admission, mechanical ventilation, AKI and mortality, suggesting the addition of pulmonary embolism to COVID-19 exacerbates morbidity and mortality. Additionally, the majority of this cohort had PESI scores >85, which has previously been shown to predict higher short-term adverse events and mortality.17 When we applied such risk predictor to this COVID-19 population, high risk patients required significantly more ICU level care, increased LOS in the hospital, and experienced a higher mortality rate.
Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes
2018, Annals of Emergency MedicineCitation Excerpt :For example, at least 10% of patients discharged home had a history of cancer; had tachypnea (respiratory rate 24 to 30 breaths/min), tachycardia (pulse 100 to 110 beats/min), or low oxygen saturation (90% to 94%) at some point in their out-of-hospital or ED stay; or had a pulmonary embolism in the main pulmonary artery. Approximately one third of our cohort were categorized as higher risk by the Pulmonary Embolism Severity Index (classes III to V), a proportion similar to that of ED patients with acute pulmonary embolism who were safely discharged home from Ottawa Hospital.48 As we have shown elsewhere, a patient’s estimated 30-day all-cause mortality is an important variable in the initial site-of-care calculus, but it is not the only variable that influences the disposition decision.32
Risk stratifying emergency department patients with acute pulmonary embolism: Does the simplified Pulmonary Embolism Severity Index perform as well as the original?
2016, Thrombosis ResearchCitation Excerpt :Both the European Society of Cardiology and the American College of Chest Physicians recommend using either the PESI or the sPESI to help identify low-risk patients who may be eligible for outpatient management [16–18]. Although both indices may be safely employed for this purpose, they may not be entirely interchangeable [13,19–22]. Some studies suggest that the sPESI identifies a lower proportion of truly low-mortality patients as low risk [13,21], although this finding has not been replicated in a more contemporary multicenter U.S. community setting.
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The results from this study were presented as an oral presentation at the ISTH meeting in Kyoto.