Risk Assessment Tools Adequate for Acute Pulmonary Embolism

Geoffrey Barnes, MD, MSc

Commonly used risk tools for acute pulmonary embolism have adequate estimating ability, according to new study findings.

The findings suggested clinicians might need to integrate broad clinical information instead of relying on a single risk assessment tool to estimate mortality risk and determine management for patients with acute pulmonary embolism.

Geoffrey Barnes, MD, MSc, and colleagues assessed the performance of risk assessment scores in a modern, US cohort of patients with acute pulmonary embolism. Patients with the condition were referred for a Pulmonary Embolism Response Team (PERT) evaluation by clinical specialists. To receive a PERT consultation, the adult patient typically needs radiographically confirmed acute pulmonary embolism and the primary team has questions about managing the condition. Electronic health record data were abstracted into the PERT Consortium Pilot Registry.

The investigators calculated the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), and Bova scores for every patient with confirmed pulmonary embolism who had complete data required to calculate each risk score. A European Society of Cardiology (ESC) risk was also assigned to each patient based on the presence of shock or hypotension, signs of right ventricular dysfunction on echocardiogram or computed tomography, and elevated cardiac biomarkers.

Patients were also categorized according to the risk categories from the derivation studies. The team included 5 risk classes for PESI and low risk and high-risk score for sPESI. For Bova score, patients were categorized into 3 risk groups excluding those with hypotension.

Barnes and the investigators assessed patient survival at standard intervals in the pilot registry. They assessed for all-cause death at any time from hospital presentation to 7 days and up to 30 days.

The analysis included 416 adults with a mean age of 61.3 years old and there were almost equal amounts of men (49.8%) as women. Almost 50% of the patients received anticoagulation therapy alone, with fewer receiving thrombolysis (7.7%), thrombectomy (2.6%), or other advanced interventions (25.5%).

Of the patients evaluated, all-cause death occurred within 7 days for 6% of patients and within 30 days for 12.3% of patients. Seven-day mortality in the low-risk groups ranges from 1.3% (sPESI) to 3.1% (Bova) and the 30-day mortality ranged from 2.6% (PESI) to 10.2% (Bova). The rate was 3.8% for sPESI.

For patients in the highest risk groups, the seven-day mortality ranged from 7% (sPESI) to 16.3% (Bova) and 30-day mortality ranged from 14.4% (sPESI) to 26.3% (PESI).

All risk stratification tools had modest discrimination for seven-day mortality (AUC range, .616-.666) with slightly lower discrimination for 30-day mortality (AUC range, .55-.694). Differences in AUC between different scores were small for seven-day mortality (<.05) and somewhat larger for 30-day mortality. This was especially true in comparing the Bova score with PESI (AUC difference, .13-.14) or sPESI (AUC difference, .09-.11) scores.

Future studies are needed to develop and validate better risk assessment tools to improve clinical care and pulmonary embolism-related research.

The study, “Comparison of 4 Acute Pulmonary Embolism Mortality Risk Scores in Patients Evaluated by Pulmonary Embolism Response Teams,” was published online in JAMA Network Open.