Point-of-Care Guides

Identifying Patients with Newly Diagnosed Acute Pulmonary Embolism Who Are at Low Risk of Death

 

Am Fam Physician. 2018 Jun 15;97(12):811-812.

Author disclosure: No relevant financial affiliations.

Clinical Question

What is the best way to identify patients with acute pulmonary embolism (PE) who are at low risk of complications or death and may be candidates for early discharge?

Evidence Summary

Standard management of acute PE includes five days of inpatient treatment with parenteral anticoagulation, followed by long-term oral anticoagulation as an outpatient. However, guidelines from the American College of Chest Physicians state that early discharge before five days can be considered in some low-risk patients who have adequate home circumstances.1 These patients should meet four criteria: (1) clinically stable with good cardiopulmonary reserve; (2) no contraindications to anticoagulation, including recent bleeding; (3) no severe renal disease, liver disease, or thrombocytopenia; and (4) likely to adhere to therapy and feel well enough to be treated at home. Adequate home circumstances include well-maintained living conditions, a good support network, and the ability to be rehospitalized promptly if necessary.2

A recent meta-analysis identified 11 clinical decision rules that predict mortality in patients with newly diagnosed acute PE.2 The three rules with the highest sensitivity and the strongest evidence are the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and the European Society of Cardiology guidelines for the management of PE.

The PESI predicts 30-day outcomes in patients with PE and was created using 15,531 inpatients from 168 hospitals in the Pennsylvania Health Care Cost Containment Council database.3  It includes 11 clinical characteristics that are assigned different point values; the cumulative score puts patients in one of five risk categories (eTable A). It uses only objective information from the history and physical examination and does not require laboratory or radiographic testing.

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eTABLE A

Identifying Low-Risk Patients with Pulmonary Embolism Who May Be Candidates for Early Hospital Discharge Using the Original PESI and ESC Guidelines

Clinical characteristic

Points


Age

1 per year of age

Male sex

10

History of cancer

30

History of heart failure

10

History of chronic lung disease

10

Heart rate ≥ 110 beats per minute

20

Systolic blood pressure < 100 mm Hg

30

Respiratory rate ≥ 30 breaths per minute

20

Temperature < 96.8°F (36°C)

20

Altered mental status

60

Oxygen saturation < 90% on room air

20

Total:

______

Risk class

Points

30-day mortality


I (very low risk)

≤ 65

0.0% to 1.6%

II (low risk)

66 to 85

1.7% to 3.5%

III (intermediate risk)

86 to 105

3.2% to 7.1%

IV (high risk)

106 to 125

4.0% to 11.4%

V (very high risk)

> 125

10.0% to 23.9%


ESC = European Society of Cardiology; PESI = Pulmonary Embolism Severity Index.

Information from 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(8):1043.

eTABLE A

Identifying Low-Risk Patients with Pulmonary Embolism Who May Be Candidates for Early Hospital Discharge Using the Original PESI and ESC Guidelines

Clinical characteristic

Points


Age

1 per year of age

Male sex

10

History of cancer

30

History of heart failure

10

History of chronic lung disease

10

Heart rate ≥ 110 beats per minute

20

Systolic blood pressure < 100 mm Hg

30

Respiratory rate ≥ 30 breaths per minute

20

Temperature < 96.8°F (36°C)

20

Altered mental status

60

Oxygen saturation < 90% on room air

20

Total:

______

Risk class

Points

30-day mortality


I (very low risk)

≤ 65

0.0% to 1.6%

II (low risk)

66 to 85

1.7% to 3.5%

III (intermediate risk)

86 to 105

3.2% to 7.1%

IV (high risk)

106 to 125

4.0% to 11.4%

V (very high risk)

> 125

10.0% to 23.9%


ESC = European Society of Cardiology; PESI = Pulmonary Embolism Severity Index.

Information from 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(8):1043.

The sPESI reduces the number of clinical characteristics to six and assigns one point for each. It was validated in 3,982 patients from an emergency department in Madrid, Spain.4 Overall, the sensitivity improved from 88.5% with the original PESI to 96% with the sPESI. The sPESI had the same positive predictive value of 11% and a higher negative predictive value (99% vs. 97.5%). Risk stratification was also simplified to two risk categories—low and high risk. Low-risk patients with an sPESI score of 0 had a 30-day mortality rate of 1% (95% confidence interval, 0.7% to 1.5%), whereas high-risk patients had a 30-day mortality rate of 9% (95% confidence interval, 8.1% to 9.8%).

The European Society of Cardiology guidelines classify low-risk patients as those with a low-risk PESI score (risk class I or II using the original PESI and a score of 0 using the sPESI), as well as no shock or hypotension, no signs of right ventricular dysfunction on imaging, and no abnormality of cardiac biomarkers.5  Importantly, the European Society of Cardiology guidelines do

Address correspondence to Pete Yunyongying, MD, at pete.yunyongying@carle.com. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease. Chest. 2016;149(2):315–352....

2. Kohn CG, Mearns ES, et al. Prognostic accuracy of clinical prediction rules for early post-pulmonary embolism all-cause mortality. Chest. 2015;147(4):1043–1062.

3. 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(8):1041–1046.

4. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383–1389.

5. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism [published corrections appear in Eur Heart J. 2015; 36(39): 2666 and Eur Heart J. 2015;36(39): 2642]. Eur Heart J. 2014;35(43):3033–3069

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision making at the point of care.

This series is coordinated by Mark H. Ebell, MD, MS, Deputy Editor for Evidence-Based Medicine.

A collection of Point-of-Care Guides published in AFP is available at https://www.aafp.org/afp/poc.

 

 

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