External validation of three risk stratification rules in patients presenting with pulmonary embolism and cancer

Abstract

Numerous risk stratification rules exist to predict post-pulmonary embolism (PE) mortality; however, few were designed for use in cancer patients. In the EPIPHANY registry, adapted versions of common rules (the Hestia criteria, Pulmonary Embolism Severity Index [PESI], and simplified PESI [sPESI]) displayed high sensitivity for prognosticating mortality in PE patients with cancer. These adapted rules have yet to be externally validated. Therefore, we sought to evaluate the performance of an adapted Hestia criteria, PESI, and sPESI for predicting 30-day post-PE mortality in patients with cancer. We identified consecutive, adults presenting with objectively confirmed PE and cancer to our institution (November 2010 to January 2014). The proportion of patients categorized as low or high risk by these three risk stratification rules was calculated, and each rule's accuracy for predicting 30-day all-cause mortality was determined. Of the 124 patients with PE and active cancer identified, 25 (20%) experienced mortality at 30 days. The adapted Hestia criteria categorized 23 (19%) patients as low risk, while exhibiting a sensitivity of 88% (95% confidence interval [CI] = 68-97%), a negative predictive value NPV of 87% (95% CI = 65-97%), and a specificity of 20% (95% CI = 13-30%). A total of 38 (31%) and 30 (24%) patients were low risk by the adapted PESI and sPESI, with both displaying sensitivities of 92% and NPVs> 93%. Specificities were 36% (95% CI = 27-47%) and 28% (95% CI = 20-38%) for PESI and sPESI. In our external validation, the adapted Hestia, PESI, and sPESI demonstrated high sensitivity but low specificity for 30-day PE mortality in patients with cancer. Larger, prospective trials are needed to optimize strategies for risk stratification in this population.

Prognostic Performance of Hestia Criteria in Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis

“…The summary characteristics of the 8 included articles were presented in Table 1. Among these studies, five 3,8,9,13,15 conducted in Europe, two 14,17 conducted in USA, and China 16 carried out one record. Published between 2013 and 2021, the enrolled eight studies consisted of four prospective studies and other four studies were retrospective.…”

“…After carefully reviewing full texts of remaining literatures, 4 articles were removed due to overlapping data. Finally, 8 eligible articles 3,8,9,[13][14][15][16][17] with 4110 participants were enrolled in this metaanalysis. The detailed flow chart of literature selection is shown in Figure 1.…”

High D-dimer is a predictor for short-term mortality in patients with active cancer and acute pulmonary embolism

“…However, the prognostic accuracy of PESI in patients with cancer diminished compared with its accuracy in the whole population [8]. Similarly, it was demonstrated that PESI showed high sensitivity but low specificity for 30day mortality in cancer patients with PE [7,22]. Weeda et al [23] reported that cancer-specific prognostic models, including POMPE-C, RIETE, and Font criteria, show better prognostic accuracy than generic tools, including PESI.…”

“…Similar to the PESI, the sPESI was also shown to be useful in identifying low-risk patients with PE [6]. However, the prognostic accuracy of the generic prognostic tools, including the PESI and sPESI was suboptimal in patients with active cancer and acute PE [7]. Several cancer-specific tools, such as POMPE-C and RIETE have been created [8].…”

Pulmonary Embolism in the Cancer Associated Thrombosis Landscape

“…In cancer patients, PE presentation is less symptomatic and is commonly with nonspecific symptoms possibly related to the cancer itself [ 44 ]. The frequency of the symptoms as reported in the literature are summarized in Figure 3 [ 45 ].…”