Simplified CRB-65 for risk stratification and predicting prognosis in acute pulmonary embolism

K. Keller; M. Coldewey; W. Dippold; J. Beule; J. O. Balzer

doi:10.12687/phleb2251-4-2015

Phlebologie, Table of Contents

Phlebologie 2015; 44(04): 192-199
DOI: 10.12687/phleb2251-4-2015

Original article

Schattauer GmbH

Simplified CRB-65 for risk stratification and predicting prognosis in acute pulmonary embolism

Vereinfachter CRB-65 zur Risikostratifizierung und Prognosevorhersage bei Patienten mit akuter Lungenarterienembolie)

K. Keller

¹Department of Medicine II, University Medical Center Mainz (Johannes Gutenberg-University Mainz)

²Center for thrombosis and haemostasis, University Medical Center Mainz

,

M. Coldewey

¹Department of Medicine II, University Medical Center Mainz (Johannes Gutenberg-University Mainz)

²Center for thrombosis and haemostasis, University Medical Center Mainz

,

W. Dippold

³sup>Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM)

,

J. Beule

³sup>Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM)

,

J. O. Balzer

⁴Department of Radiology and Nuclear medicine, Catholic Clinic Mainz (KKM)

⁵Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/ Main

› Author Affiliations

Abstract

Summary

Background: Pulmonary embolism (PE) and community acquired pneumonia (CAP) are potentially life-threatening diseases. In CAP CRB-65 is used for risk stratification and prognosis prediction. The aim of this study was to examine a simplified CRB-65 (sCRB-65) for predicting prognosis in PE.

Methods: We retrospectively analyzed the data of 182 PE patients. Patients were, according to the score of sCRB-65 (respectively 1 point for dyspnoea, systolic blood pressure < 90 mmHg or diastolic blood pressure60 mmHg, age65years), subdivided in risk-classes 1–4.

Risk classes were compared with Kruskal-Wallis test. Logistic multivariable regression and Pearson correlation matrix were calculated for coherence of sCRB-65 and in-hospital death, right ventricular load and PE severity stadium as well as sCRB-65 > 2points and in-hospital death an PE stadium. ROC analysis was performed to evaluate efficiency of sCRB-65 score to predict in-hospital death and PE severity stadium.

Results: PE severity stadium, systolic pulmonary artery pressure (sPAP) and frequency of in-hospital death increased with growing risk class.

Risk class 1 showed lower PE sever-ity stadium than 2 (P=0.0253), 3 (P=0.0132) and 4 (P=0.00162), lower percentage of patients with sPAP > 30mmHg than 2 (0 % vs. 48.9 %, P=0.0419), 3 (0 % vs. 70.8 %, P=0.00112) and 4 (0 % vs. 75.0 %, P=0.0113). Frequency of in-hospital deaths was higher in risk class 4 than in 1 (P=0.0024), 2 (P=0.00014) and 3 (P=0.000058). Multi-variable logistic regression showed an association between sCRB-65 scored>0 and PE severity stadium (OR 11.42, 95 %CI: 1.35–96.66, P=0.0254), RVD (OR 10.09, 1.16–87.78, P=0.0363) and sPAP (OR 1.08, 1.02–1.15, P=0.0092) as well as a trend towards significance (OR 12.39, 0.90–171.34, P=0.060) between in-hospital death and sCRB-65. sCRB-65 correlated with PE severity stadium (r=0.258, P<0.001) and sPAP (r=0.280, P=0.001). sCRB-65 >2 points was strongly associated with both inhospital death (OR 36.22, 95%CI: 1.59–827.71, P=0.0245) and high-risk PE stadium (OR 57.94, 95%CI: 7.17–468.33, P=0.000141). ROC analysis for CRB-65 predicting in-hospital death and high-risk PE stadium showed AUC values of respectively 0.764 and 0.892 with sCRB-65 cut-off value of 2.5 points, respectively.

Conclusions: sCRB-65 is closely correlated with PE severity stadium and load of the right heart as well as prognosis. PE patients with sCRB-65 score >2 points revealed a 36.2-fold risk to die during in-hospital course after acute PE event. Efficiency of sCRB-65 to predict in-hospital death was good.

Zusammenfassung

Hintergrund: Lungenarterienembolie (PE) und ambulant erworbene Pneumonie (CAP) sind potenziell lebensbedrohende Erkrankungen. Bei Patienten mit CAP wird der CRB-65 genutzt, um eine Risikostratifizierung durchzuführen und eine Prognose abzuschätzen. Das Ziel der vorliegenden Untersuchung war es, einen vereinfachten CRB-65 (sCRB-65) zur Vorhersage der Prognose von PE-Patienten zu begutachten.

Methoden: Wir haben retrospektiv die Daten von 182 PE-Patienten analysiert. Die Patienten wurden, entsprechend den zugeteilten Punkten des sCRB-65 (jeweils 1 Punkt für Dyspnoe, systolischer Blutdruck <90 mmHg und/oder diastolischer Blutdruck 60 mmHg und Alter 65 Jahre), in die Risikoklassen 1–4 eingeteilt.

Die Risikoklassen wurden mittels Kruskal-Wallis-Test verglichen. Logistische multi-variable Regressionsmodelle und eine Pearson-Korrelationsmatrix wurden berechnet, um eine Assoziationen zwischen sCRB-65 und jeweils Versterben im Krankenhaus, rechtsventrikulärer Belastung, PE-Schweregrad, weiterhin sCRB-65 >2 Punkte und dem Versterben im Krankenhaus sowie dem PE-Schweregrad zu untersu-chen. Zudem wurde eine ROC-Analyse, zur Beurteilung der Effektivität, mittels sCRB-65-Punkte-Score ein Versterben im Krankenhaus und einen höheren PE-Schweregrad vorherzusagen, durchgeführt.

Ergebnisse: PE-Schweregrad, systolischer pulmonal-arterieller Druck (sPAP) und die Häufigkeit eines Versterbens im Krankenhaus nahmen mit anwachsender Risikoklasse zu. Patienten der Risikoklasse 1 zeigten im Durchschnitt einen niedrigeren PE-Schweregrad als Risikoklasse 2 (P=0,0253), 3 (P=0,0132) und 4 (P=0,00162), einen niedrigeren Anteil an Patienten mit einem sPAP >30 mmHg als Klasse 2 (0 % vs. 48,9 %, P=0,0419), 3 (0 % vs. 70,8 %, P=0,00112) und 4 (0 % vs. 75,0 %, P=0,0113). Die Häufigkeit eines Versterben im Krankenhaus war in Risikoklasse 4 höher als in Klasse 1 (P=0,0024), 2 (P=0,00014) und 3 (P=0,000058). Die multi-variablen logistischen Regressionsmodelle zeigten eine Assoziation zwischen sCRB-65 >0 und sowohl PESchweregrad (OR 11,42, 95%CI: 1,35–96,66, P=0,0254), rechtsventrikulärer Dysfunktion (RVD) (OR 10,09, 95%CI: 1,16–87,78, P=0.0363) und sPAP (OR 1,08, 95%CI: 1,02–1,15, P=0,0092) als auch einen Trend zu einer Signifikanz (OR 12,39, 95%CI: 0,90–171,34, P=0,060) zwischen einem Versterben im Krankenhaus und sCRB-65. Der sCRB-65 korrelierte mit dem PE-Schweregrad (r=0,258, P<0,001) und dem sPAP (r=0,280, P=0,001). Ein sCRB-65 Wert über 2 Punkten war eng mit sowohl einem Versterben im Krankenhaus (OR 36,22, 95%CI: 1,59–827,71, P=0,0245) als auch einem Hochrisiko-PESchweregrad (OR 57,94, 95%CI: 7,17–468,33, P=0,000141) assoziiert.

Die ROC-Analyse für die Vorhersage eines Versterbens im Krankenhaus und eines Hochrisiko-PE-Schweregrades durch den sCRB-65 zeigte eine Fläche unter der Kurve (AUC) von jeweils 0,764 und 0,892 mit einem sCRB-65-cut-off-Wert von jeweils 2,5 Punkten.

Schlussfolgerungen: Der sCRB-65 korreliert sowohl mit dem PE-Schweregrad und der Rechtsherzbelastung als auch mit der Prognose bei PE-Patienten. PE-Patienten mit einem sCRB-65-Punktwert von >2 Punkten zeigten ein 36,2-fach erhöhtes Risiko, während des initialen Krankenhausaufenthalts nach einem PE-Ereignis zu versterben. Die Effektivität des sCRB-65 zur Vorhersage eines Versterbens im Krankenhaus war gut. Normotensive PE-Patienten unter 65 Jahren ohne Dyspnoe zeigten die beste Prognose.

Keywords

Pulmonary artery pressure - risk stratification - pulmonary embolism - right ventricular dysfunction - CRB-65 - thrombosis

Schlüsselwörter

Risiskostratifizierung - Lungenarterienembolie - rechtsventrikuläre Dysfunktion - CRB-65 - Thrombose

Full Text

References

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