Is Advanced Risk Stratification Unnecessary In Patients with Simplified Pulmonary Embolism Severity Index (sPESI) of 0?

Abstract

Aim: The European Society Cardiology guidelines state that advanced risk stratification is unnecessary in patients with simplified pulmonary embolism severity index (sPESI) of 0 because it does not affect treatment decision. Also, these patients can be discharged early or treated as outpatients if feasible. There were three aims of the present study. The first was to determine the rate of patients with sPESI of 0 but classified into intermediate risk category with advanced risk stratification. is the second was to determine the clinical impact of this risk classification change. And the third was to define risk factors for this condition. Patients and Methods: This is prospective single-center cohort study. All patients underwent advanced risk stratification at admission independent from the sPESI score. Patients with a sPESI score 0 were included. Results: There were 33 patients with sPESI score of 0. With advanced risk stratification; 60.6% of patients were low risk, 30.3% were intermediate low risk and 9.1% were intermediate-high risk. In 2 (6.1%) patients, respiratory failure developed. One of these patients became hypotensive and required thrombolytic treatment. D-dimer value (p=0.017) and thrombus in main pulmonary arteries (p=0.000) were statistically significantly high in intermediate risk group. Conclusions: Advanced risk stratification in sPESI 0 patients has an impact on management decisions. Early discharge or outpatient treatment decisions based on sPESI alone may cause the discharge of unstable patients especially in patients with main pulmonary artery thromboembolism or D-dimer level over 3600 ng/ml.

Keywords

• Pulmonary Thromboembolism
• Clinical Risk Score
• Simplified Pulmonary Embolism Severity Index

Basitleștirilmiș Pulmoner Emboli Ağırlık İndeks (SPESI) Skoru 0 Olan Olgularda İleri Risk Sınıflaması Gereksiz Mi?

Abstract

Amaç: Avrupa Kardiyoloji Derneği (ESC), risk sınıflama modeline göre, akut pulmoner tromboemboli (PTE) olgularında eğer basitleștirilmiș pulmoner emboli ağırlık indeksi (sPESI) 0 ise ileri risk sınıflaması gereksizdir. Bu olgular erken taburcu edilebilir veya uygun olanlar ayaktan tedavi edilebilir. Bu çalıșmanın üç amacı vardı. Birincisi; sPESI 0 olduğu halde ileri risk sınıflaması ile orta riskli saptanan olguların oranı, ikincisi; bu durum için risk faktörlerinin saptanması ve üçüncüsü de risk sınıflaması değișikliğinin klinik üzerindeki etkilerinin saptanmasıdır. Gereç ve Yöntem: Tek merkezde yapılan bu prospektif kuhort çalıșmada olguların hepsine sPESI skorlarından bağımsız olarak bașvuru anında eko ve kardiyak biomarkerlar ile ileri risk sınıflaması yapıldı. sPESI skoru 0 olan olgular çalıșmaya dahil edildi. Bulgular: PTE tanısı alan toplam 109 olgu vardı. Bunlardan 33’ünde sPESI skoru 0 idi. İleri risk sınıflaması ile bu 33 olgunun %60,6’sı düșük , %30,3’ü orta düșük ve %9,1’i orta yüksek riskti. Olguların hepsi yatarak tedavi edildi. Takipte İki (%6,1) olguda solunum yetmezliği geliști ve bu olgulardan birisinde hipotansyon gelișmesi nedeniyle trombolitik uygulandı. D-dimer değeri (p=0.017) ve ana pulmoner arterlerde trombus olması (p=0.000) orta riskli grupta istatistiksel olarak anlamlı derecede daha yüksekti. Sonuç: Sadece sPESI skoruna göre ayaktan tedavi veya erken taburculuk kararı verilmesi özellikle ana pulmoner arterlerde emboli olan veya D-dimer değeri 3600 ng/ml üzerinde olan ve aslında unstabil olan olguların taburculuğuna neden olabilir.

Keywords

• Pulmoner Tromboemboli
• Klinik Risk Skorları
• Basitleștirilmiș Pulmoner Emboli Ağırlık İndeksi

References

1. 1. Heit JA. Epidemiology of venous thromboembolism. Nat Rev Cardiol. 2015; 12: 464-474.
2. 2. Riva N, Donadini MP, Ageno W. Epidemiology and pathophysiology of venous thromboembolism: similarities with atherothrombosis and the role of inflammation. Thromb Haemost 2015; 113: 1176–1183.
3. 3. 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: 3033-3069
4. 4. Hellenkamp K, Kaeberich A, Schwung J, et al. Risk stratification of normotensive pulmonary embolism based on the sPESI - Does it work for all patients? Int J Cardiol. 2015; 197: 162-163.
5. 5. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am JRespirCrit Care Med. 2005; 172: 1041- 1046.
6. 6. Jiménez D, Yusen RD, Otero R, et al. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. Chest. 2007; 132: 24- 30.
7. 7. Aujesky D, Perrier A, Roy PM, et al. Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med. 2007; 261: 597-604.
8. 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: 41-48.

9. 9. Jiménez D, Aujesky D, Moores Let al. RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010; 170: 1383-1389.
10. 10. Righini M, Roy PM, Meyer G, et al. The Simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism. J Thromb Haemost. 2011; 9: 2115-2117.
11. 11. Erkens PM, Gandara E, Wells PS, et al. Does the Pulmonary Embolism Severity Index accurately identify low risk patients eligible for outpatient treatment? Throm Res. 2012; 129: 710-714.