Thromb Haemost 2021; 121(12): 1660-1667
DOI: 10.1055/a-1475-2263
Stroke, Systemic or Venous Thromboembolism

Validation of the 2019 European Society of Cardiology Risk Stratification Algorithm for Pulmonary Embolism in Normotensive Elderly Patients

1   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
,
Christine Baumgartner
1   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
,
Marie Méan
2   Division of General Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
,
Odile Stalder
3   CTU Bern, University of Bern, Bern, Switzerland
,
Andreas Limacher
3   CTU Bern, University of Bern, Bern, Switzerland
,
Nicolas Rodondi
1   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
4   Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
,
Drahomir Aujesky
1   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
› Author Affiliations
Funding This work was supported by a grant from the Swiss National Science Foundation (grant numbers 33CSCO-122659, 139470). The sponsor had no role in the design and conduct of the study, in the collection, analysis, interpretation of the data, in the writing process, or in the decision to submit the article for publication.

Abstract

Background The 2019 European Society of Cardiology (ESC) guidelines recommend evaluation for right ventricular dysfunction in all normotensive patients with acute pulmonary embolism (PE). We compared the predictive performance of the 2019 and 2014 ESC risk stratification algorithms and the Pulmonary Embolism Severity Index (PESI).

Methods We performed a posthoc analysis of normotensive patients aged ≥ 65 years with acute PE from a prospective cohort. The primary outcome was overall mortality; secondary outcomes were PE-related mortality and adverse outcomes (PE-related death, cardiopulmonary resuscitation, intubation, catecholamine use, recurrent venous thromboembolism) at 30 days. We assessed outcomes in intermediate-high, intermediate-low, and low-risk groups according to the 2019 and 2014 ESC algorithms and the PESI. Discriminative power was compared using the area under the receiver operating characteristic curve (AUC).

Results Among 419 patients, 14 (3.3%) died (7 from PE) and 16 (3.8%) had adverse outcomes within 30 days. The 2019 ESC algorithm classified more patients as intermediate-high risk (45%) than the 2014 ESC algorithm (24%) or the PESI (37%), and only 19% as low risk (32% with 2014 ESC or the PESI). Discriminatory power for overall mortality was lower with the 2019 ESC algorithm (AUC: 63.6%), compared with the 2014 ESC algorithm (AUC: 71.5%) or the PESI (AUC: 75.2%), although the difference did not reach statistical significance (p = 0.063). Discrimination for PE-related mortality and adverse outcomes was similar.

Conclusion While categorizing more patients in higher risk groups, the 2019 ESC algorithm for PE did not improve prediction of short-term outcomes compared with the 2014 ESC algorithm or the PESI.

Author Contributions

All authors participated in the research and preparation of the manuscript. Study concept and design: D. Aujesky. Data acquisition: D. Aujesky, Marie Méan. Data analysis and interpretation: J. Moor, C. Baumgartner, Marie Méan, N. Rodondi, D. Aujesky. Drafting of the manuscript: J. Moor, C. Baumgartner, D. Aujesky. Critical revision of the manuscript: J. Moor, O. Stalder, A. Limacher, Marie Méan, C. Baumgartner, N. Rodondi, D. Aujesky. Statistical analyses: O. Stalder, A. Limacher. Study supervision: D. Aujesky, C. Baumgartner. Approval of the final manuscript: all authors.


Supplementary Material



Publication History

Received: 08 January 2021

Accepted: 01 April 2021

Accepted Manuscript online:
06 April 2021

Article published online:
28 May 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353 (9162): 1386-1389
  • 2 Jiménez D, Bikdeli B, Barrios D. et al; RIETE investigators. Epidemiology, patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism. Int J Cardiol 2018; 269: 327-333
  • 3 Stein PD, Matta F. Treatment of unstable pulmonary embolism in the elderly and those with comorbid conditions. Am J Med 2013; 126 (04) 304-310
  • 4 Konstantinides SV, Meyer G, Becattini C. et al; The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): the Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019; 54 (03) 54
  • 5 Becattini C, Agnelli G, Lankeit M. et al. Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model. Eur Respir J 2016; 48 (03) 780-786
  • 6 Méan M, Righini M, Jaeger K. et al. The Swiss cohort of elderly patients with venous thromboembolism (SWITCO65+): rationale and methodology. J Thromb Thrombolysis 2013; 36 (04) 475-483
  • 7 Kabrhel C, Okechukwu I, Hariharan P. et al. Factors associated with clinical deterioration shortly after PE. Thorax 2014; 69 (09) 835-842
  • 8 Aujesky D, Roy PM, Verschuren F. et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378 (9785): 41-48
  • 9 Aujesky D, Obrosky DS, Stone RA. et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005; 172 (08) 1041-1046
  • 10 Konstantinides SV, Torbicki A, Agnelli G. et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (43) 3033-3069
  • 11 Kannel WB, Belanger AJ. Epidemiology of heart failure. Am Heart J 1991; 121 (3, Pt 1): 951-957
  • 12 Fragoso CA. Epidemiology of chronic obstructive pulmonary disease (COPD) in aging populations. COPD 2016; 13 (02) 125-129
  • 13 Bova C, Greco F, Misuraca G. et al. Diagnostic utility of echocardiography in patients with suspected pulmonary embolism. Am J Emerg Med 2003; 21 (03) 180-183
  • 14 Kurzyna M, Torbicki A, Pruszczyk P. et al. Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism. Am J Cardiol 2002; 90 (05) 507-511
  • 15 Vuilleumier N, Simona A, Méan M. et al. Comparison of cardiac and non-cardiac biomarkers for risk stratification in elderly patients with non-massive pulmonary embolism. PLoS One 2016; 11 (05) e0155973
  • 16 Méan M, Tritschler T, Limacher A. et al. Association between computed tomography obstruction index and mortality in elderly patients with acute pulmonary embolism: a prospective validation study. PLoS One 2017; 12 (06) e0179224
  • 17 Barco S, Mahmoudpour SH, Planquette B, Sanchez O, Konstantinides SV, Meyer G. Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2019; 40 (11) 902-910
  • 18 Hobohm L, Becattini C, Konstantinides SV, Casazza F, Lankeit M. Validation of a fast prognostic score for risk stratification of normotensive patients with acute pulmonary embolism. Clin Res Cardiol 2020; 109 (08) 1008-1017
  • 19 Andrade I, García A, Mercedes E. et al. Need for transthoracic echocardiogram in patients with low-risk pulmonary thromboembolism: a systematic review and meta-analysis. Arch Bronconeumol 2020; 56 (05) 306-313
  • 20 Vanni S, Nazerian P, Pepe G. et al. Comparison of two prognostic models for acute pulmonary embolism: clinical vs. right ventricular dysfunction-guided approach. J Thromb Haemost 2011; 9 (10) 1916-1923
  • 21 Zondag W, Mos IC, Creemers-Schild D. et al; Hestia Study Investigators. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011; 9 (08) 1500-1507
  • 22 Frank Peacock W, Coleman CI, Diercks DB. et al. Emergency department discharge of pulmonary embolus patients. Acad Emerg Med 2018; 25 (09) 995-1003
  • 23 Hendriks SV, Klok FA, den Exter PL. et al. Right ventricle-to-left ventricle diameter ratio measurement seems to have no role in low-risk patients with pulmonary embolism treated at home triaged by Hestia criteria. Am J Respir Crit Care Med 2020; 202 (01) 138-141
  • 24 Hendriks SV, Lankeit M, den Exter PL. et al; Vesta Investigators. Uncertain value of high-sensitive troponin t for selecting patients with acute pulmonary embolism for outpatient treatment by Hestia criteria. Acad Emerg Med 2020; 27 (10) 1043-1046
  • 25 McCormack T, Harrisingh MC, Horner D, Bewley S. Guideline Committee. Venous thromboembolism in adults: summary of updated NICE guidance on diagnosis, management, and thrombophilia testing. BMJ 2020; 369: m1565
  • 26 Lim W, Le Gal G, Bates SM. et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv 2018; 2 (22) 3226-3256
  • 27 Barco S, Valerio L, Ageno W. et al. Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000-18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database. Lancet Respir Med 2021; 9 (01) 33-42
  • 28 Casazza F, Becattini C, Bongarzoni A. et al. Clinical features and short term outcomes of patients with acute pulmonary embolism. The Italian Pulmonary Embolism Registry (IPER). Thromb Res 2012; 130 (06) 847-852