DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20151168

Comparison and combination of a hemodynamics/biomarkers-based model with simplified PESI score for prognostic stratification of acute pulmonary embolism: findings from a real world study

Luca Masotti, Grazia Panigada, Giancarlo Landini, Filippo Pieralli, Francesco Corradi, Salvatore Lenti, Rino Migliacci, Carlo Nozzoli, Maddalena Grazzini, Lucia Ciucciarelli, Alessandro Morettini, Sara Bucherelli, Alessandra Petrioli, Carlotta Casati, Mario Felici, Luciano Ralli, Stefano Arrigucci, Laila Teghini, Giovanni Antonio Porciello, Stefano Spolveri, Daniele Baldoni, Anna Frullini, Barbara Cimolato, Gianni Lorenzini, Alessandro Pampana, Guidantonio Rinaldi, Maria Chiara Bertieri, Raffaele Laureano, Stefano Tatini, Alberto Fortini, Chiara Angotti, Valerio Verdiani, Anna Maria Romagnoli, Irene Cascinelli, Alberto Camaiti, Nicola Mumoli, Marco Cei, Stefano Giuntoli, Massimo Alessandri, Alessandro De Palma, Maurizio Manini, Veronica De Crescenzo, Michele Piacentini, Carlo Passaglia, Giancarlo Tintori, Carlo Palermo, Alba Dainelli, Roberto Andreini, Giuseppa Levantino, Plinio Fabiani, Lucia Raimondi, Massimo Di Natale, Filippo Risaliti, Rossella Nassi, Roberta Mastriforti, Roberto Cappelli, Michele Voglino, Paola Lambelet, Stefano Fascetti, Adriano Cioppi, Valentina Carli, Alessandro Tafi, Simone Meini, Emilio Santoro, Claudia Rosi

Abstract


Background: Prognostic stratification is of utmost importance for management of acute Pulmonary Embolism (PE) in clinical practice. Many prognostic models have been proposed, but which is the best prognosticator in real life remains unclear. The aim of our study was to compare and combine the predictive values of the hemodynamics/biomarkers based prognostic model proposed by European Society of Cardiology (ESC) in 2008 and simplified PESI score (sPESI).

Methods: Data records of 452 patients discharged for acute PE from Internal Medicine wards of Tuscany (Italy) were analysed. The ESC model and sPESI were retrospectively calculated and compared by using Areas under Receiver Operating Characteristics (ROC) Curves (AUCs) and finally the combination of the two models was tested in hemodinamically stable patients. All cause and PE-related in-hospital mortality and fatal or major bleedings were the analyzed endpoints

Results: All cause in-hospital mortality was 25% (16.6% PE related) in high risk, 8.7% (4.7%) in intermediate risk and 3.8% (1.2%) in low risk patients according to ESC model. All cause in-hospital mortality was 10.95% (5.75% PE related) in patients with sPESI score ≥1 and 0% (0%) in sPESI score 0. Predictive performance of sPESI was not significantly different compared with 2008 ESC model both for all cause (AUC sPESI 0.711, 95% CI: 0.661-0.758 versus ESC 0.619, 95% CI: 0.567-0.670, difference between AUCs 0.0916, p=0.084) and for PE-related mortality (AUC sPESI 0.764, 95% CI: 0.717-0.808 versus ESC 0.650, 95% CI: 0.598-0.700, difference between AUCs 0.114, p=0.11). Fatal or major bleedings occurred in 4.30% of high risk, 1.60% of intermediate risk and 2.50% of low risk patients according to 2008 ESC model, whereas these occurred in 1.80% of high risk and 1.45% of low risk patients according to sPESI, respectively. Predictive performance for fatal or major bleeding between two models was not significantly different (AUC sPESI 0.658, 95% CI: 0.606-0.707 versus ESC 0.512, 95% CI: 0.459-0.565, difference between AUCs 0.145, p=0.34). In hemodynamically stable patients, the combined endpoint in-hospital PE-related mortality and/or fatal or major bleeding (adverse events) occurred in 0% of patients with low risk ESC model and sPESI score 0, whilst it occurred in 5.5% of patients with low-risk ESC model but sPESI ≥1. In intermediate risk patients according to ESC model, adverse events occurred in 3.6% of patients with sPESI score 0 and 6.65% of patients with sPESI score ≥1.

Conclusions: In real world, predictive performance of sPESI and the hemodynamic/biomarkers-based ESC model as prognosticator of in-hospital mortality and bleedings is similar. Combination of sPESI 0 with low risk ESC model may identify patients with very low risk of adverse events and candidate for early hospital discharge or home treatment.

 


Keywords


Pulmonary embolism, Prognosis, Biomarkers; PESI, Echocardiography, Bleeding, ESC

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