Abstract
Background Acute pulmonary embolism (PE) is burdened by high mortality, especially within 30 days from the diagnosis. The development and the validation of predictive models for the risk of early mortality allow to differentiate patients who can undergo home treatment from those who need admission into intensive care units. Methods To validate the prognostic model for early mortality after PE diagnosis proposed by the European Society of Cardiology (ESC) in 2014, we analyzed data of a cohort of 272 consecutive patients with acute PE, observed in our hospital during a 10-year period. Moreover, we evaluated the additional contribution of D-dimer, measured at PE diagnosis, in improving the prognostic ability of the model. All cases of PE were objectively diagnosed by angiography chest CT scan or perfusion lung scan. Results The overall mortality rate within 30 days from PE diagnosis was 10% (95% confidence interval [CI]: 6.4–13.5%). According to the ESC prognostic model, the risk of death increased 3.23 times in the intermediate-low-risk category, 5.55 times in the intermediate-high-risk category, and 23.78 times in the high-risk category, as compared with the low-risk category. The receiver operating characteristic analysis showed a good discriminatory power of the model (area under the curve [AUC] = 0.77 [95% CI: 0.67–0.87]), which further increased when D-dimer was added (AUC = 0.85 [95% CI: 0.73–0.96]). Conclusion This study represents a good validation of the ESC predictive model whose performance can be further improved by adding D-dimer plasma levels measured at PE diagnosis.
Highlights
Pulmonary embolism (PE) is a common cardiovascular disease with high mortality
The receiver operating characteristic analysis showed a good discriminatory power of the model, which further increased when D-dimer was added (AUC 1⁄4 0.85 [95% confidence intervals (CI): 0.73–0.96])
Of the 272 patients with objectively confirmed acute PE evaluated at the emergency department of our hospital between 2005 and 2015, twenty-seven died within 30 days, for a death rate of 10.0%
Summary
In 2014, the European Society of Cardiology (ESC) proposed a prognostic model for early mortality (i.e., within 30 days) after PE diagnosis based on integrated clinical, laboratory, and instrumental parameters,[7] which identifies four categories of early mortality risk: high, intermediate-high, intermediatelow, and low risk.[8,9] The definition of risk category is based on hemodynamic instability, class of Pulmonary Embolism Severity Index (PESI), evidence of right ventricle dysfunction (documented by echocardiography or computed tomography [CT] angiography), and elevated cardiac biomarker levels, that is, troponins or pro-brain natriuretic peptide (proBNP) This model allows to differentiate patients who can undergo home treatment (low-risk category), reducing hospital costs, from those who need admission into intensive care units from the early stages of the acute event (high-risk category).[10,11] according to a recent study in which the ability of the 2014 ESC model to predict 30-day mortality was assessed, the risk stratification in patients at intermediate risk requires further improvement.[8]. The development and the validation of predictive models for the risk of early mortality allow to differentiate patients who can undergo home treatment from those who need admission into intensive care units
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