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Published on: September 6, 2024
Identification of Low-Risk Patients with Acute Symptomatic Pulmonary Embolism for Outpatient Therapy
Ana Maestre1, Javier Trujillo-Santos2, Antoni Riera-Mestre3
11 Department of Internal Medicine, Hospital Universitario del Vinalopo, Elche, Alicante, Spain.
Insights
A new RIETE score identifies low-risk pulmonary embolism (PE) patients for outpatient care. This score outperforms existing models like PESI and sPESI for predicting short-term complications.
Area of Science:
- Cardiology
- Pulmonary Medicine
- Clinical Prediction Models
Background:
- Acute symptomatic pulmonary embolism (PE) management may involve outpatient treatment for low-risk patients.
- Accurate risk stratification is crucial for determining appropriate patient disposition.
Purpose of the Study:
- To develop and validate a clinical prediction rule for identifying PE patients at low risk of short-term complications.
- To compare the prognostic ability of the new rule against the Pulmonary Embolism Severity Index (PESI) and Simplified PESI (sPESI).
Main Methods:
- Utilized multivariable logistic regression on a large international cohort of PE patients from the RIETE registry.
- Prospectively enrolled patients were analyzed to identify predictors of early complications.
Main Results:
- The developed RIETE score demonstrated superior prognostic ability compared to PESI and sPESI (AUC 0.77 vs. 0.72 and 0.71).
- Key predictors included chronic heart failure, recent immobilization, recent major bleeding, cancer, hypotension, tachycardia, hypoxemia, renal insufficiency, and abnormal platelet count.
- The RIETE score significantly outperformed PESI and sPESI in net reclassification and integrated discrimination improvements.
Conclusions:
- A novel RIETE score, derived from widely available variables, effectively identifies PE patients at low risk for short-term complications.
- This score can aid in patient triage and potentially reduce hospital stay duration.
Rationale:
Patients with acute symptomatic pulmonary embolism (PE) deemed to be at low risk for early complications might be candidates for partial or complete outpatient treatment.
Objectives:
To develop and validate a clinical prediction rule that accurately identifies patients with PE and low risk of short-term complications and to compare its prognostic ability with two previously validated models (i.e., the Pulmonary Embolism Severity Index [PESI] and the Simplified PESI [sPESI])
Methods:
Multivariable logistic regression of a large international cohort of patients with PE prospectively enrolled in the RIETE (Registro Informatizado de la Enfermedad TromboEmbólica) registry.
Measurements And Main Results:
All-cause mortality, recurrent PE, and major bleeding up to 10 days after PE diagnosis were determined. Of 18,707 eligible patients with acute symptomatic PE, 46 (0.25%) developed recurrent PE, 203 (1.09%) bled, and 471 (2.51%) died. Predictors included in the final model were chronic heart failure, recent immobilization, recent major bleeding, cancer, hypotension, tachycardia, hypoxemia, renal insufficiency, and abnormal platelet count. The area under receiver-operating characteristic curve was 0.77 (95% confidence interval [CI], 0.75-0.78) for the RIETE score, 0.72 (95% CI, 0.70-0.73) for PESI (P < 0.05), and 0.71 (95% CI, 0.69-0.73) for sPESI (P < 0.05). Our RIETE score outperformed the prognostic value of PESI in terms of net reclassification improvement (P < 0.001), integrated discrimination improvement (P < 0.001), and sPESI (net reclassification improvement, P < 0.001; integrated discrimination improvement, P < 0.001).
Conclusions:
We built a new score, based on widely available variables, that can be used to identify patients with PE at low risk of short-term complications, assisting in triage and potentially shortening duration of hospital stay.
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