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Prognostic value of the simplified PESI score in comparison with the 2014 ESC risk model in pulmonary embolism

2016; Elsevier BV; Volume: 220; Linguagem: Inglês

10.1016/j.ijcard.2016.06.305

1874-1754

Elena‐Mihaela Cordeanu, S. Gærtner, Alix Faller, C. Mirea, Isabelle Le Ray, Dominique Stéphan,

Diagnosis and Treatment of Venous Diseases

Pulmonary embolism (PE) is a frequent, potentially fatal condition. The first 30 days following diagnosis and anticoagulant treatment initiation represent a higher risk period for recurrent venous thromboembolism (VTE), bleeding and death [ [1] van Gogh Investigators Buller H.R. Cohen A.T. Davidson B. Decousus H. Gallus A.S. Gent M. et al. Idraparinux versus standard therapy for venous thromboembolic disease. N. Engl. J. Med. 2007; 357: 1094-1104 Crossref PubMed Scopus (310) Google Scholar ]. Thus, several prognostic models have been developed in order to detect patients at higher risk of complication during this acute phase [ [2] Jiménez D. Lobo J.L. Barrios D. Prandoni P. Yusen R.D. Risk stratification of patients with acute symptomatic pulmonary embolism. Intern. Emerg. Med. 2016; 11: 11-18 Crossref PubMed Scopus (35) Google Scholar ]. In 2008, the European Society of Cardiology (ESC) adopted a three-level risk classification: (a) high risk in case of haemodynamic instability, (b) intermediate risk in case of cardiac biomarkers elevation and/or echocardiographic right ventricular (RV) dysfunction and (c) low risk in the absence of biomarkers elevation or right heart dysfunction [ [3] Torbicki A1. Perrier A. Konstantinides S. Agnelli G. Galiè N. Pruszczyk P. et al. ESC Committee for Practice Guidelines (CPG). 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). Eur. Heart J. 2008; 29: 2276-2315 Crossref PubMed Scopus (1912) Google Scholar ]. Since then, the Pulmonary Embolism Severity Index (PESI) and its simplified version (sPESI) integrating age, comorbidities, blood pressure, heart rate and oxygen saturation have been validated in the estimation of mortality risk at 30 days [ 4 Donze ́.J. Le Gal G. Fine M.J. Roy P.M. Sanchez O. Verschuren F. et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism. Thromb. Haemost. 2008; 100: 943-948 Crossref PubMed Scopus (230) Google Scholar , 5 Righini M. Roy P.M. Meyer G. Verschuren F. Aujesky D. Le Gal G. The simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism. J. Thromb. Haemost. 2011; 9: 2115-2117 Crossref PubMed Scopus (104) Google Scholar ]. The latest ESC guidelines (2014) implemented the PESI/sPESI scores in the management of PE [ [6] Konstantinides S.V. Torbicki A. Agnelli G. Danchin N. Fitzmaurice D. Galiè N. et al. Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur. Heart J. 2014; 35 (3069a-3069 k): 3033-3069 Crossref PubMed Scopus (2205) Google Scholar ]. In brief, haemodynamically stable PE patients should initially be assessed by the PESI/sPESI scores. A low PESI score (class I, II) or a simplified PESI of 0 are associated with a lower risk of early mortality (0.6 to 1%), sparing the need for cardiac biomarkers and RV function assessment. Higher PESI classes (III-V) or a sPESI score of at least 1, impose a biological and echocardiographic evaluation and are further on stratified in intermediate low and intermediate high risk patients and their mortality risk may rise up to 11% at 30 days [ [6] Konstantinides S.V. Torbicki A. Agnelli G. Danchin N. Fitzmaurice D. Galiè N. et al. Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur. Heart J. 2014; 35 (3069a-3069 k): 3033-3069 Crossref PubMed Scopus (2205) Google Scholar ]. The first category of patients might benefit from an early discharge or an ambulatory treatment while the latter needs a closer monitoring during the initial phase [ [6] Konstantinides S.V. Torbicki A. Agnelli G. Danchin N. Fitzmaurice D. Galiè N. et al. Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur. Heart J. 2014; 35 (3069a-3069 k): 3033-3069 Crossref PubMed Scopus (2205) Google Scholar ]. Other prognostic models, such as the Hestia criteria or the shock index have been proposed but less frequently used. The laborious Hestia clinical decision rule requires at least 24 h of hospital stay and its value for outpatient treatment remains inconclusive, while the shock index proved to have a poor sensitivity [ 7 den Exter P.L. Zondag W. Klok F.A. Brouwer R.E. Dolsma J. Eijsvogel M. et al. Efficacy and safety of outpatient treatment based on the Hestia Clinical Decision Rule with or without NT-proBNP testing in patients with acute pulmonary embolism: a randomized clinical trial. Am. J. Respir. Crit. Care Med. 2016; https://doi.org/10.1164/rccm.201512-2494OC Crossref PubMed Scopus (97) Google Scholar , 8 Sam A. Sanchez D. Gomez V. Wagner C. Kopecna D. Zamarro C. 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 Crossref PubMed Scopus (65) Google Scholar ].