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Clinical Prediction Rule for Stratifying Patients with PE



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Am Fam Physician. 2006 Aug 15;74(4):658-660.

More than 100,000 persons in the United States were hospitalized with pulmonary embolism (PE) in 2002. These hospitalizations resulted in 676,700 inpatient days. Among patients with PE, the short-term mortality rate varies from less than 2 percent for those with nonmassive PEs to 95 percent for patients with cardiorespiratory arrest. Models for the risk stratification of PE are not well established, and those in place are dependent on arterial blood gas analysis and leg vein ultrasound. Aujesky and colleagues set out to develop a purely clinical prediction rule for stratifying the risk of mortality or other adverse medical outcomes in patients with PE with the intent that low-risk patients can be treated in an outpatient setting.

A study population of 15,531 was developed from patients added to the Pennsylvania Health Care Cost Containment Council database from January 2000 to November 2002. The population was based on a primary discharge diagnosis of PE or a secondary diagnosis of PE combined with a primary diagnosis of cardiorespiratory failure, cardiogenic shock, cardiac arrest, secondary pulmonary hypertension, syncope, thrombolysis, or intubation/mechanical ventilation. The prediction rule was derived from 11 clinical variables routinely available at presentation. These variables included demographic data, comorbidities, and clinical and laboratory findings. Using logistic regression with 30-day mortality as the outcome, the authors found 11 clinical variables that were independently associated with 30-day mortality (see accompanying table). These results were validated internally and externally. The prediction rule was internally validated using 5,177 (33 percent) of the original study population. The external validation used data from 221 patients diagnosed with PE via spiral computed tomography at three university hospitals in Switzerland and one in France. Because the results from both validations were consistent with the results of the original study, the 11-variable prediction rule was highly reliable.

Each of the 11 factors was given a score to quantify the magnitude of mortality (see accompanying table). When the laboratory about the importance of being weaned from the bottle by 15 months of age.

Independent Risk Factors of 30-Day Mortality in Patients with Pulmonary Embolism

Risk factor Value

Age

Points = years

Male sex

+ 10

Cancer

+ 30

Heart failure

+ 10

Chronic lung disease

+ 10

Pulse ≥110 beats per minute

+ 20

Systolic blood pressure < 100 mm Hg

+ 30

Respiratory rate ≥30 breaths per minute

+ 20

Body temperature < 96.8°F (36°C)

+ 20

Altered mental status*

+ 60

Arterial oxygen saturation < 90 %

+ 20

Total points:

_________

Total points Risk class

≤65

I, very low risk

66 to 85

II, low risk

86 to 105

III, intermediate risk

106 to 125

IV, high risk

> 125

V, very high risk


note:A total point score is given by adding up the patient’s age in years and the points for each applicable risk factor.

*—Defined as disorientation, lethargy, stupor, or coma.

Adapted with permission from Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172:1042.

Independent Risk Factors of 30-Day Mortality in Patients with Pulmonary Embolism

View Table

Independent Risk Factors of 30-Day Mortality in Patients with Pulmonary Embolism

Risk factor Value

Age

Points = years

Male sex

+ 10

Cancer

+ 30

Heart failure

+ 10

Chronic lung disease

+ 10

Pulse ≥110 beats per minute

+ 20

Systolic blood pressure < 100 mm Hg

+ 30

Respiratory rate ≥30 breaths per minute

+ 20

Body temperature < 96.8°F (36°C)

+ 20

Altered mental status*

+ 60

Arterial oxygen saturation < 90 %

+ 20

Total points:

_________

Total points Risk class

≤65

I, very low risk

66 to 85

II, low risk

86 to 105

III, intermediate risk

106 to 125

IV, high risk

> 125

V, very high risk


note:A total point score is given by adding up the patient’s age in years and the points for each applicable risk factor.

*—Defined as disorientation, lethargy, stupor, or coma.

Adapted with permission from Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172:1042.

Brotanek JM, et al. Iron deficiency, prolonged bottle-feeding, and racial/ethnic disparities in young children. Arch Pediatr Adolesc Med. November 2005;159:1038–42.



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