Andrew S. Dunn, MD
In normotensive patients with acute pulmonary embolism (PE), do the simplified Pulmonary Embolism Severity Index (sPESI) and high-sensitivity troponin T (hsTnT) assay predict risk for short-term adverse outcomes?
Cohort study with prospective external validation of 2 previously derived prediction guides (sPESI and hsTnT assay).
12 centers in Spain, Germany, and Poland.
526 patients (median age 71 y, 51% men) who had high clinical probability of acute PE using the Wells score or low or intermediate clinical probability using the Wells score plus a D-dimer test result ≥ 0.5 mg/L, confirmed by computed tomography, lung scan, or echocardiography. Exclusion criteria included hemodynamic instability and incidental finding of PE.
The sPESI included 6 items, each scoring 1 point: age > 80 years, history of cancer, history of chronic cardiopulmonary disease, heart rate ≥ 110 beats per min, systolic blood pressure 90 to 100 mm Hg, and arterial oxyhemoglobin saturation < 90% at PE diagnosis; score ≥ 1 = high risk. The hsTnT assay measured cardiac troponin T levels in samples collected at admission; ≥ 14 pg/mL = high risk.
Adverse outcome (all-cause mortality, cardiopulmonary resuscitation, endotracheal intubation, or need for intravenous catecholamine for tissue perfusion or cardiogenic shock) at 30 days. Other outcomes included symptomatic, recurrent PE at 30 days, major bleeding at 30 days, and all-cause mortality at 6 months.
5.9% of patients had an adverse 30-day outcome, and 9.9% died over 6 months. In multivariable analyses, both sPESI and hsTnT assay predicted adverse outcomes at 30 days, and sPESI predicted mortality at 6 months (Table). Low- and high-risk groups had similar rates of recurrent PE (sPESI, 1.0% vs 2.1%, P = 0.49; hsTnT assay, 1.4% vs 1.9%, P = 0.74) and major bleeding (sPESI, 2.0% vs 3.4%, P = 0.43; hsTnT assay, 1.4% vs 3.8%, P = 0.12). sPESI ≥ 1 point and hsTnT assay ≥ 14 pg/mL had similar sensitivity (94% vs 87%), specificity (40% vs 42%), and area under the receiver-operating characteristic curve (0.67, 95% CI 0.59 to 0.75 vs 0.73, CI 0.65 to 0.82) for predicting 30-day adverse outcomes.
The simplified Pulmonary Embolism Severity Index and the high-sensitivity troponin T assay each predicted short-term adverse outcomes in normotensive patients with acute pulmonary embolism.
sPESI and hsTnT assay for predicting adverse outcomes in normotensive patients with acute pulmonary embolism*
*HR = hazard ratio; hsTnT = high-sensitivity troponin T; OR = odds ratio; sPESI = simplified Pulmonary Embolism Severity Index; CI defined in Glossary.
†SPESI: score 0 = low risk (n = 198), score ≥ 1 = high risk (n = 328); hsTnT assay: < 14 pg/mL = low risk (n = 214), ≥ 14 pg/mL = high risk (n = 312).
‡Multivariable analyses included dichotomous measures for sPESI and hsTnT (information provided by author).
§Multivariable analyses included dichotomous measures for sPESI and hsTnT, right ventricular dysfunction, and glomerular filtration rate < 60 mL/min/1.73 m2.
Dunn AS. The simplified Pulmonary Embolism Severity Index and high-sensitivity troponin T predicted prognosis in PE. Ann Intern Med. 2012;156:JC4–12. doi: 10.7326/0003-4819-156-8-201204170-02012
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Published: Ann Intern Med. 2012;156(8):JC4-12.
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