Association between the Pulmonary Embolism Severity Index (PESI) and short-term clinical deterioration

Abstract

The Pulmonary Embolism Severity Index (PESI) has been shown to predict 30 and 90 day mortality after PE. However, whether the PESI predicts patients who will be free of clinically adverse outcomes during a typical hospitalisation is not known. Retrospective analysis of Emergency Department patients with PE from May 2006 to April 2008. We compiled demographics, data to calculate the PESI and a composite outcome. Patients were considered to have a negative PESI if they were in category I or II (≤85 points). Patients were considered to have the composite outcome if, within five days of diagnosis, they: A) had recurrent PE; B) developed a new cardiac dysrhythmia; C) required advanced cardiac life support; D) required respiratory support; E) required vasopressors; F) received thrombolysis; G) had major bleeding; H) returned to the ED; I) died. We enrolled 245 patients with PE. Of these, 115 (47%) were male, 204 (83%) were white. The mean age was 57 ± 17 years. The PESI identified 109 (44%) as low risk and 136 (56%) as high risk. Sixty-one (26%) patients had the outcome, of whom nine (14%) were characterised as low risk by the PESI. Test characteristics were: sensitivity 86% (95% confidence interval [CI]: 75%-93%), specificity 55% (95% CI: 47%-62%), NPV 63% (95% CI: 55%-70%), PPV 40% (95% CI: 31%-49%), LR(+) 1.9 (95% CI: 1.57-2.30) and LR(-) 0.26 (95% CI: 0.14-0.48). Of the patients who had an adverse clinical event or required a hospital-based intervention within the first five days after PE diagnosis, 14% were categorised by the PESI as safe for discharge [corrected] .

Factors associated with clinical deterioration shortly after PE

“…Study staff interviewed each patient, their nurses and reviewed the medical record every day for 5 days to identify clinical deterioration events. Five days is consistent with the median length of stay for PE in our institution as well as the timeframe cited as most relevant to the disposition of a patient with PE in a survey of clinicians 20 22 23…”

Association Between Electrocardiographic Findings, Right Heart Strain, and Short‐Term Adverse Clinical Events in Patients With Acute Pulmonary Embolism

“…15 This timeframe was chosen based on prior literature and is consistent with a typical length of hospitalization for PE. 16 …”

Impact of Relative Contraindications to Home Management in Emergency Department Patients with Low-Risk Pulmonary Embolism

“…We adopted and adapted the definitions of major 5-day inpatient adverse events from researchers at Massachusetts General Hospital (8,9,19). These included clot extraction or lysis (local or systemic), respiratory support (a non-rebreather mask or more), new cardiac dysrhythmia requiring treatment, use of intravenous vasopressors or inotropics, use of defibrillation or cardiopulmonary resuscitation, recurrent PE, major hemorrhage (defined below), and death.…”

“…The latter, however, could strongly influence decision making about hospitalizing patients or assigning them to immediate ambulatory care (19). Two single-center retrospective studies have tested the performance characteristics of the PE Severity Index with a novel application: to predict the risk of short-term inpatient decompensation (9,10). These studies found an inpatient adverse event rate up to 8% for their low-risk PE populations.…”

“…Two single-center retrospective case series tested the PE Severity Index in this capacity but failed to account for relative contraindications to outpatient care (9,10). Contraindications, however, are commonly used in various combinations throughout the prospective outpatient PE literature as well as in outpatient management protocols (2,3,11,12).…”