Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis

Abstract

ObjectiveTo review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes.DesignSystematic review and meta-analysis.Data sourcesOVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature.Eligibility criteriaStudies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE.Data extractionStudy characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers.Data analysisSummary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy.ResultsWe included 71 studies (44 298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5–1%) and those at higher risk (up to 20–29% of event rate).ConclusionsWe provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.

Acute pulmonary embolism: a concise review of diagnosis and management

“…The three most sensitive CPS are the PESI, sPESI and ESC guideline risk stratification criteria, with sensitivities of 0.89, 0.92 and 0.88, respectively, with the sPESI (Table ) as the most validated . A sPESI score = 0 (‘low risk’) has a reported 30‐day mortality rate of 1.0–1.5%, while a score ≥1 (‘high risk’) is 10.7–10.9%, but can be over 20% in haemodynamically unstable patients . When determining from low‐ to intermediate‐risk patients, the sPESI score alone appears superior to other markers of right heart dysfunction (i.e.…”

“…5,45,46 A sPESI score = 0 ('low risk') has a reported 30-day mortality rate of 1.0-1.5%, while a score ≥1 ('high risk') is 10.7-10.9%, but can be over 20% in haemodynamically unstable patients. 9,47,48 When determining from low-to intermediate-risk patients, the sPESI score alone appears superior to other markers of right heart dysfunction (i.e. cardiac troponin, 49 CTPA and electrocardiography (ECG) 5,17,18 ).…”

Oxygen saturation or respiratory rate to improve risk stratification in hemodynamically stable patients with acute pulmonary embolism

“…Several studies showed that more than 50% of patients with acute PE are hemodynamically stable at presentation and are not at low risk of death according to clinical models . In these ‘intermediate‐risk’ patients, several predictors for death have been identified but their clinical value and their optimal use (alone or in combination) are debated .…”

Is oxygen saturation variable of simplified pulmonary embolism severity index reliable for identification of patients, suitable for outpatient treatment

“…1,2 There are several risk stratification models for this purpose. 3,4 PESI and sPESI were initially designed and validated for the prediction of short-term mortality, but recent studies have revealed that PESI or sPESI can accurately select patients eligible for outpatient treatment. 3,4 PESI and sPESI were initially designed and validated for the prediction of short-term mortality, but recent studies have revealed that PESI or sPESI can accurately select patients eligible for outpatient treatment.…”

“…3,4 The pulmonary embolism severity index (PESI) or simplified version (sPESI) are the most widely validated of these scores with similar accuracy. 3,4 PESI and sPESI were initially designed and validated for the prediction of short-term mortality, but recent studies have revealed that PESI or sPESI can accurately select patients eligible for outpatient treatment. [5][6][7][8][9][10][11] In contrast to PESI, sPESI has six variables with equal points (Table 1).…”