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Simplified PESI identified low-risk pulmonary embolism
BY AMY KARON
FROM ACADEMIC EMERGENCY MEDICINE
Vitals Key clinical point: The simplified version of the PESI identified low-risk pulmonary embolism patients. Major finding: Patients with scores of 0 or 1 had low rates of major adverse events during the first 30 days, regardless of which treatment they received. Data source: Post hoc analysis of simplified PESI scores and outcomes among 4,831 patients with acute pulmonary embolism who received either rivaroxaban or an enoxaparin–vitamin K antagonist combination. Disclosures:Bayer HealthCare Pharmaceuticals and Janssen Research & Development funded the study. Dr Fermann reported an advisory relationship with Janssen and research funding from Cardiorentis, Trevena, Novartis, Siemens, and Pfizer. Two coauthors reported employment with Bayer, and two other coauthors reported relationships with several other pharmaceutical companies. |
A simplified version of the Pulmonary Embolism Severity Index identified patients with acute pulmonary embolism who were at low risk of adverse events and might be suitable for outpatient care.
“Although guidelines, such as those from the American College of Chest Physicians, recommend outpatient treatment for selected PE patients at low risk of recurrence, existing evidence for the outpatient management of patients with PE is derived from small cohorts of patients from outside the United States,” said Dr Gregory J. Fermann of the University of Cincinnati department of emergency medicine and his associates. “Risk stratification of PE patients may allow a cohort of low-risk patients to be treated in a clinical decision unit or by a closely monitored outpatient strategy. Such an approach might relieve some of the burden placed on the emergency department,” they wrote (Acad. Emerg. Med. 2015;22:299-307).
The simplified PESI includes 6 of the 11 variables measured in PESI, which has been shown to identify patients at increased risk of death and adverse outcome events after acute PE. The six features of the simplified PESI are age greater than 80 years, history of cancer, history of chronic cardiopulmonary disease, heart rate of at least 110 beats per minutes, systolic blood pressure less than 100 mm Hg, and oxygen saturation less than 90%. Each factor is assigned a score of 1.
They carried out a post hoc analysis of simplified PESI scores and outcomes among 4,831 acute PE patients from the EINSTEIN-PE study of rivaroxaban and an enoxaparin–vitamin K antagonist combination (N. Engl. J. Med. 2012;366:1287-97).
Roughly half (53.6%) of the patients had a score of 0, one-third (36.7%) had a score of 1, and 9.7% had a score of 2 or 3, the researchers reported. Higher simplified PESI scores were associated with increased risk of almost all adverse outcomes measured, including recurrent VTE, fatal PE, all-cause mortality, and major bleeding. Patients with scores of 0 or 1 had low rates of major adverse events during the first 30 days of treatment, regardless of which protocol they received. Scores of 2 or 3 were associated with greater risk of recurrent VTE, fatal PE, all-cause mortality, and major bleeding in both treatment groups.
