Chest
Volume 132, Issue 1, July 2007, Pages 24-30
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ORIGINAL RESEARCH
PULMONARY VASCULAR DISEASE
Prognostic Models for Selecting Patients With Acute Pulmonary Embolism for Initial Outpatient Therapy

https://doi.org/10.1378/chest.06-2921Get rights and content

Objective:

To assess the performance of two prognostic models in predicting short-term mortality in patients with pulmonary embolism (PE).

Subjects and methods:

We compared the test characteristics of two prognostic models for predicting 30-day outcomes (mortality, thromboembolic recurrences, and major bleeding) in a cohort of 599 patients with objectively confirmed PE. Patients were stratified into the PE severity index (PESI) risk classes I-V and the Geneva low-risk and high-risk strata. We compared the discriminatory power of both prognostic models.

Results:

The PESI classified fewer patients as low risk (strata I and II) [36%; 216 of 599 patients; 95% confidence interval (CI), 32 to 40%] compared to the Geneva prediction rule (84%; 502 of 599 patients; 95% CI, 81 to 87%) [p < 0.0001]. Using either prediction rule, the low-risk groups showed statistically relevant 30-day mortality difference (PESI, 0.9%; 95% CI, 0.3 to 2.2; vs Geneva, 5.6%; 95% CI, 3.6 to 7.6) [p < 0.0001], although nonfatal recurrent venous thromboembolism or major bleeding rates were statistically similar (PESI, 2.8%; 95% CI, 0.6 to 5.0%; vs Geneva, 4.2%; 95% CI, 2.4 to 5.9%). The area under the receiver operating characteristic curve was higher for the PESI (0.76; 95% CI, 0.69 to 0.83) than for the Geneva score (0.61; 95% CI, 0.51 to 0.71) [p = 0.002].

Conclusions:

The PESI quantified the prognosis of patients with PE better than the Geneva score. This study demonstrated that PESI can select patients with very low adverse event rates during the initial days of acute PE therapy and assist in selecting patients for treatment in the outpatient setting.

Section snippets

Study Design

For a prospective registry, we attempted to enroll all patients with a diagnosis of acute PE between January 1, 2003, and September 30, 2006. Using prospectively collected baseline data at the time of PE diagnosis and outcome data from this cohort, we retrospectively assessed the test characteristics of the Geneva prognostic model and the PESI for predicting 30-day mortality, nonfatal recurrent venous thromboembolism (VTE), and nonfatal major bleeding. We also compared the performance of both

Results

Of the 2,219 patients evaluated for possible acute symptomatic PE during the study period, 624 patients (28%) had objectively confirmed PE. Of these, 9 patients (1.4%) refused to give informed consent, producing a study sample of 615 patients. Since 16 patients (2.6%) were unavailable for follow-up, the evaluable population consisted of 96.0% (599 patients) of eligible patients with acute PE.

Compared to patients in the PESI derivation sample,7 patients in this validation cohort more frequently

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      Citation Excerpt :

      Table 2 highlights the PESI and sPESI scores. Multiple studies have demonstrated that patients with low PESI scores (group I) had mortality less than 1% compared with high PESI group (group V) with 24% 30-day mortality.33–35 D-dimer is a fibrin degradation product.

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    Drs. D. Jiménez, R. Otero, F. Uresandi, D. Nauffal, E. Laserna, F. Conget, M. Oribe, and M.A. Cabezudo are investigators in the Cooperative Study for the Ambulatory Treatment of Patients With Pulmonary Embolism research group.

    Then authors have no conflicts of interest to disclose.

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