Risk Stratification Of Pulmonary Embolism Research Articles

Clinical Presentation and Risk Stratification of Pulmonary Embolism

AbstractPulmonary embolism (PE) presents with a spectrum of symptoms, ranging from asymptomatic cases to life-threatening events. Common symptoms include sudden dyspnea, chest pain, limb swelling, syncope, and hemoptysis. Clinical presentation varies based on thrombus burden, demographics, and time to presentation. Diagnostic evaluation involves assessing symptoms, physical examination findings, and utilizing laboratory tests, including D-dimer. Risk stratification using tools like Wells score, Pulmonary Embolism Severity Index, and Hestia criteria aids in determining the severity of PE. PE is categorized based on hemodynamic status, temporal patterns, and anatomic locations of emboli to guide in making treatment decisions. Risk stratification plays a crucial role in directing management strategies, with elderly and comorbid individuals at higher risk. Early identification and appropriate risk stratification are essential for effective management of PE. As we delve into this review article, we aim to enhance the knowledge base surrounding PE, contributing to improved patient outcomes through informed decision-making in clinical practice.

Evaluation of soluble P-selectin as a predictive biomarker in acute symptomatic pulmonary embolism: Insights from a prospective observational study.

Soluble P-selectin (sP-selectin) has been proposed as a potential biomarker for venous thromboembolism (VTE) diagnosis with interesting results. However, its role in predicting early mortality in pulmonary embolism (PE) remains unexplored. This observational, prospective, single-center study enrolled consecutive patients aged 18 or older with confirmed acute symptomatic PE and no prior anticoagulation. The study aims to assess the prognostic capacity of sP-selectin measured at the time of PE diagnosis for short-term mortality and major bleeding. A total of 196 patients, with a mean age of 69.1 years (SD 17), were included, of whom 52.6% were male. Within 30 days, 9.7% of patients (n = 19) died, and 5.1% (n = 10) suffered major bleeding. PE risk stratification revealed 4.6% (n = 9) with high-risk PE, 34.7% (n = 68) with intermediate-high-risk PE, 38.3% (n = 75) with intermediate-low-risk PE, and 22.5% (n = 44) with low-risk PE according to the European Society of Cardiology score. Mean plasma sP-selectin levels were comparable between survivors and non-survivors (489.7 ng/mL ±63 vs. 497.3 ng/mL ±51; p = .9). The ROC curve for 30-day all-cause mortality and major bleeding yielded an AUC of 0.49 (95% CI 0.36-0.63) and 0.46 (95% CI 0.24-0.68), respectively. Multivariate and survival analyses were precluded due to lack of significance. sP-selectin was not useful for predicting short-term mortality or major bleeding in patients with acute symptomatic pulmonary embolism. Further studies are required to clarify the role of sP-selectin in VTE, particularly in prognosticating PE outcomes.

Differentiating electrocardiographic indications of massive and submassive pulmonary embolism: A cross-sectional study in Southern Iran from 2015 to 2020.

Although using electrocardiogram (ECG) for pulmonary embolism (PE) risk stratification has shown mixed results, it is currently used as supplementary evidence in risk stratification. This cross-sectional study aimed to assess and compare ECG findings of massive and submassive PE versus segmental PE. This cross-sectional study included 250 hospitalized patients with a confirmed diagnosis of acute PE from 2015 to 2020 in Southern Iran. Demographic variables, clinical data, troponin levels, on-admission ECG findings, echocardiography findings, and ECG findings 24 h after receiving anticoagulants or thrombolytics were extracted. Patients diagnosed with submassive or massive PE exhibited significantly higher rates of right axis deviation (p = .010), abnormal ST segment (p < .0001), S1Q3T3 pattern (p < .0001), inverted T wave in leads V1-V3 (p < .0001), inverted T wave in leads V4-V6 (p < .0001), and inverted T wave in leads V1-V6 (p < .0001). In a multivariable model, inverted T wave in leads V1-V3, inverted T wave in leads V4-V6, pulse rate, and positive troponin test were the statistically independent variables for predicting submassive or massive PE. Furthermore, inverted T wave in leads V1-V3 (sensitivity: 85%, specificity: 95%, accuracy: 93%, AUC: 0.902) and troponin levels (sensitivity: 72%, specificity: 86%, accuracy: 83%, AUC: 0.792) demonstrated the best diagnostic test performance for discriminating submassive or massive PE from segmental PE. In addition to clinical rules, ECG can serve as an ancillary tool for assessing more invasive testing and earlier aggressive treatments among patients with PE, as it can provide valuable information for the diagnosis and risk stratification of submassive or massive PE.

Evaluation of Pulmonary Embolism Risk Stratification Scores in Patients Admitted to the Internal Medicine Clinic

Evaluation of Pulmonary Embolism Risk Stratification Scores in Patients Admitted to the Internal Medicine Clinic

Enhancing Pulmonary Embolism Mortality Risk Stratification Using Machine Learning: The Role of the Neutrophil-to-Lymphocyte Ratio.

(1) Background: Acute pulmonary embolism (PE) is a significant public health concern that requires efficient risk estimation to optimize patient care and resource allocation. The purpose of this retrospective study was to show the correlation of NLR (neutrophil-to-lymphocyte ratio) and PESI (pulmonary embolism severity index)/sPESI (simplified PESI) in determining the risk of in-hospital mortality in patients with pulmonary thromboembolism. (2) Methods: A total of 160 patients admitted at the County Clinical Emergency Hospital of Sibiu from 2019 to 2022 were included and their hospital records were analyzed. (3) Results: Elevated NLR values were significantly correlated with increased in-hospital mortality. Furthermore, elevated NLR was associated with PESI and sPESI scores and their categories, as well as the individual components of these parameters, namely increasing age, hypotension, hypoxemia, and altered mental status. We leveraged the advantages of machine learning algorithms to integrate elevated NLR into PE risk stratification. Utilizing two-step cluster analysis and CART (classification and regression trees), several distinct patient subgroups emerged with varying in-hospital mortality rates based on combinations of previously validated score categories or their defining elements and elevated NLR, WBC (white blood cell) count, or the presence COVID-19 infection. (4) Conclusion: The findings suggest that integrating these parameters in risk stratification can aid in improving predictive accuracy of estimating the in-hospital mortality of PE patients.

Pulmonary embolism risk stratification: external validation of the 4-level Clinical Pretest Probability Score (4PEPS)

BackgroundThe 4-level clinical pretest probability score (4PEPS) was recently introduced as a clinical decision rule for the diagnosis of pulmonary embolism (PE). Based on the score, patients are classified into clinical pretest probability categories (c-PTP). The “very low” category aims at excluding PE without further testing; “low” and “moderate” categories require D-dimer testing with specific thresholds, while patients with a “high” pretest directly proceed to imaging. ObjectivesTo provide further external validation of the 4PEPS model. MethodsThe 4PEPS was applied to a previously collected prospective database of 756 patients with clinically suspected PE enrolled from European emergency departments in 2002 to 2003. The safety threshold for the failure rate in our study was calculated at 1.95% based on a 26% prevalence of PE in our study, as per the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee guidance. ResultsPatients were classified as follows: 90 (12%) in the very low c-PTP group, of whom 5 (5.6%; 95% CI, 2.4%-12.4%) had PE; 363 (49%) in the low c-PTP group, of whom 34 had PE (9.4%); 246 (34%) in the moderate c-PTP group, of whom 124 (50%) had PE; and 35 (5%) in the high c-PTP group of whom 30 (86%) had PE. Overall, the failure rate of the 4PEPS was 9/734 (1.2%; 95% CI, 0.59%-2.23%) Overall, 9 out of 734 patients (1.2%; 95% CI, 0.59%-2.23%) were diagnosed with PE despite a negative 4PEPS rule; 5 (5.6%) from the very low c-PTP group, 3 (1.4%) in the low c-PTP group, and 1 (3.2%) in the moderate c-PTP group. ConclusionWe provide external validation data of the 4PEPS. In this high-prevalence cohort (26% prevalence), PE prevalence in the very low-risk group was higher than expected. A prospective validation study is needed before implementing the 4PEPS model in routine clinical practice.

Pulmonary Embolism Triage: When to Do What.

Anticoagulation has been the standard therapy for treating pulmonary embolism. However, newly developed pharmacological and interventional treatment options have been shown to provide benefit for certain patient populations, depending on how they present. This column highlights the use of massive pulmonary embolism risk stratification in determining the presence of cor pulmonale and offers several key points to remember when caring for patients with a pulmonary embolism.

Discharge from the emergency department and outpatient clinic in cancer patients with acute symptomatic and incidental pulmonary embolism: A multicenter retrospective cohort study

BackgroundIt is unclear how often cancer patients with acute pulmonary embolism (PE) are discharged from the emergency department (ED) or outpatient clinic and whether direct discharge is safe. We assessed treatment setting and early safety outcomes in cancer patients with acute symptomatic and incidental PE. MethodsCancer patients diagnosed with PE at the ED or outpatient clinic between August 2017 and May 2021 were included in Four Cities VTE Cancer, a Dutch multicenter retrospective cohort study. The main outcome was direct discharge versus hospitalization. Safety outcomes were cumulative 14-day mortality and PE-related readmission incidences. ResultsWe included 602 patients (median age 71 years; 49.5 % female) of whom 285 (47.3 %) were discharged directly and 317 (52.7 %) were hospitalized. The cumulative 14-day mortality incidence was 0.7 % (95 % CI, 0.1–2.4 %) in patients discharged directly and 9.0 % (95 % CI, 6.2–12.5 %) in those hospitalized. The cumulative 14-day PE-related readmission incidence was 1.8 % (95 % CI, 0.7–3.9 %) and 1.4 % (95 % CI, 0.5–3.3 %) in directly discharged and hospitalized patients, respectively. Of the 220 patients with incidental PE, 180 (81.8 %) were discharged directly compared to 105 of 382 (27.5 %) patients with symptomatic PE (P < 0.001). Mortality and readmission incidences in symptomatic and incidental PE were consistent with the main analysis. ConclusionsAbout 28 % and 82 % of cancer patients with symptomatic or incidental PE, respectively, were discharged directly, with low 14-day mortality and PE-related readmission incidences. These data underline the need for PE risk stratification in oncological populations and suggest that clinicians successfully identify a proportion of patients in whom direct discharge is safe.

Survey of Pulmonary Embolism Risk Stratification Methods in the Emergency Department and Barriers to Electronic Health Record Documentation

Introduction Pulmonary Embolism (PE) is a major cause of morbidity and mortality worldwide. Diagnosis is essential as untreated PE has a 30% mortality rate. Currently, computer tomography pulmonary angiogram (CTPA) is the standard of care to diagnose PE. However, this modality is expensive, exposes patients to radiation and increases risk of contrast induced nephropathy. Furthermore, only 5% of CTPAs performed are positive for PE signifying that many unnecessary tests are being performed. To address this gap, Pre-Test Probability (PTP) tools have been developed to safely exclude patients with low risk of PE and limit iatrogenic harm from over testing. Despite the tools being developed over 20 years ago, they are not widely available in electronic health record (EHR) systems and even when they are built in, uptake remains low. Methods Three large integrated health systems using Epic EHR systems across five states (MA, WI. MN, AZ, FL) built electronic PTP assessments into their EHR systems to safely exclude patients with low risk of PE and limit over testing. Two sites made the PTP optional, and one site made it a forced function (providers were forced to complete PTP prior to ordering CTPA unless a D-dimer result was present in the prior 48 hours). To assess the usability of these EHR tools, the team conducted a survey with ED clinicians across the three test sites. The survey was created to identify which PE risk stratification methods were employed by ED clinicians (EHR embedded PTP tool, apps on their phone, web applications like MDcalc, calculations from memory, or if they relied on clinical gestalt), and to identify barriers to using the EHR embedded PTP. Results Site 1 had 47 respondents, Site 2 had 94 respondents, and Site 3 had 16 respondents. Two key findings emerged from the survey (Figure 1). First, clinicians used a variety of risk stratification approaches and few of them documented their risk assessments in structured fields in the medical record. Second, clinical gestalt was the most used PE risk stratification approach, and this was true across all three test sites. In addition, the health system with a PTP prompt before clinicians could proceed with CTPA orders (Site 3) did not have a higher percentage of clinicians who reported using the EHR embedded tool than sites that did not prompt clinicians to fill in the PTP. Clinicians cited a variety of different barriers to using the EHR embedded PTP tool (Table 1). Conclusion While many clinicians indicated intermittent use of PTP criteria to aid in the diagnosis of PE, risk factors and scores from phone apps, web tools, and calculations from memory are unlikely to be documented in the patient's medical record, which means that they are not accessible to all members of the ED care team and cannot be used for electronic clinical quality measure. The biggest hurdles to increasing the use of structured PTP assessments in the ED setting to safely exclude PE and limit iatrogenic harm from over testing are (1) obtaining buy-in from ED clinicians that the PTP tools provide value over clinical gestalt, at least for a subset of patients who could most benefit, and (2) identifying best practices for incorporating PTP tools into EHR systems that make the tools easier to access and use 3) developing and implementing effective education and awareness programs around the PTP tools. This survey adds to the body of literature on PTP assessments in the ED setting and can help inform further research that is needed to continue to improve the diagnosis of PE. Funding: This project is funded in part by the Gordon and Betty Moore Foundation through Grant GBMF10778 to the American Society of Hematology.

High-Sensitivity Troponin in Pulmonary Embolism Risk Stratification—Proceed With Caution

High-Sensitivity Troponin in Pulmonary Embolism Risk Stratification—Proceed With Caution

160 The risk stratification of pulmonary embolism with the Wells-, Geneva-, modified Wells- and modified Geneva-score

160 The risk stratification of pulmonary embolism with the Wells-, Geneva-, modified Wells- and modified Geneva-score

Impact of an Institutional Clinical Pathway on Emergency Physicians' Stated Preferences in Treating Patients with Low-Risk Pulmonary Embolism.

Evidence continues to accumulate that select patients with acute low-risk pulmonary embolism (PE) can be safely discharged from the emergency department. Despite this, outpatient management continues to be uncommon. We report changes in emergency providers' stated preferences on low-risk acute PE management before and after the development and implementation of an institutional clinical pathway and decision tool. We performed an observational analysis of attending emergency physicians' stated preferences towards the management of low-risk acute PE using survey results before and after the development and implementation of an electronic health record-embedded institutional low-risk acute PE pathway. Attending emergency medicine providers reported feeling more comfortable using PE risk stratification scores to identify dischargeable low-risk PE patients and also reported that they would be more likely to discharge a hypothetical patient with low-risk acute PE. Our results suggest that the implementation of an institutional clinical pathway with integration into the electronic health record was associated with a change in emergency physicians' stated preferences for managing patients with acute low-risk PE in the emergency department. Implementation of an evidence-based standard pathway was associated with increased comfort and familiarity with PE risk stratification, and an increased comfort with and preference for early outpatient management of low-risk PE.

Mechanical thrombectomy for acute pulmonary embolism in lung transplant recipients

The rates of pulmonary embolism (PE) are high among lung transplant (LT) recipients. Management is challenging because of elevated bleeding risks and inadequacy of conventional PE risk stratification tools. New percutaneous large bore mechanical thrombectomy catheters are being increasingly used effectively to debulk thrombus and restore flow immediately. We describe the use of mechanical thrombectomy (MT) in 8 LT recipients. All patients were diagnosed with intermediate/high-risk proximal PE involving the allograft and underwent successful MT within 30hours of diagnosis. Estimated blood loss was between 200 and 450cc, with 3 patients requiring blood transfusions. Improvement in heart rate and oxygenation was seen in all 8 patients after the procedure. In the 30days after MT, 7 of 8 patients survived. One patient died from major bleeding occurred 16 days after MT and 5 days after venoarterial extracorporeal membrane oxygenator decannulation. Mechanical thrombectomy may provide a feasible management strategy in select LT recipients with pulmonary embolism.

Right-to-left ventricular ratio is higher in systole than diastole in patients with acute pulmonary embolism.

In acute pulmonary embolism (PE), the right ventricle (RV) may dilate compromising left ventricular (LV) size, thereby increasing RV/LV ratio. End-diastolic RV/LV ratio is often used in PE risk stratification, though the cause of death is RV systolic failure. We aimed to confirm our pre-clinical observations of higher RV/LV ratio in systole compared to diastole in human patients with PE. We blinded and independently analyzed echocardiograms from 606 patients with PE, evaluated by a Pulmonary Embolism Response Team. We measured RV/LV ratios in end-systole and end-diastole and fractional area change (FAC). Our primary outcome was a composite of 7-day clinical deterioration, treatment escalation or death. Secondary outcomes were 7-day and 30-day all-cause mortality. RV/LV ratio was higher in systole compared to diastole (median 1.010 [.812-1.256] vs. .975 [.843-1.149], p<.0001). RV/LV in systole and diastole were correlated (slope=1.30 [95% CI 1.25-1.35], p<.0001vs. slope=1). RV/LV ratios in both systole and diastole were associated with the primary composite outcome but not with all-cause mortality. The RV/LV ratio is higher when measured in systole versus in diastole in patients with acute PE. The two approaches had similar associations with clinical outcomes, that is, it appears reasonable to measure RV/LV ratio in diastole.

High-Risk PE: Management for the Intensivist.

High-risk pulmonary embolism (PE) also known as massive PE carries a high rate of morbidity and mortality. The incidence of high-risk PE continues to increase, yet the outcomes of high-risk PE continue to remain poor. Patients with high-risk PE are often critically ill, with complex underlying physiology, and treatment for the high-risk PE patient almost always requires care and management from an intensivist. Treatment options for high-risk PE continue to evolve rapidly with multiple options for definitive reperfusion therapy and supportive care. A thorough understanding of the physiology, risk stratification, treatment, and support options for the high-risk PE patient is necessary for all intensivists in order to improve outcomes. This article aims to provide a review from an intensivist's perspective highlighting the physiological consequences, risk stratification, and treatment options for these patients as well as providing a proposed algorithm to the risk stratification and acute management of high-risk PE.

Risk stratification of pulmonary embolism.

Pulmonary embolism is the third most frequent type of cardiovascular disease behind coronary artery disease and stroke. Patients with acute pulmonary embolism have significant variability in short-term mortality from less than 0.6% in low-risk patients to 19% in high-risk patients. Risk stratification plays an important role in the management of acute pulmonary embolism as it can determine the need for urgent reperfusion therapies versus conservative strategies. The three fundamental steps of risk stratification include the immediate identification of patients that are at high risk for mortality, the identification of patients that are at an increased risk of complications from pulmonary embolism that requires hospital monitoring and potential escalation of therapies, and the identification of patients at a low risk that can be treated as an outpatient. It is vital to immediately identify high-risk patients for mortality so that they can be evaluated for urgent reperfusion therapies to improve outcomes. Risk stratification for intermediate-risk patients is based on right ventricular dysfunction in patients with hemodynamic stability. RV dysfunction can be assessed by clinical signs and symptoms along with ECHO and cardiac biomarkers. Identifying the low-risk population can help reduce the healthcare burden by allowing for early discharge and outpatient management.

Impact of Baseline Heart Failure on Acute Pulmonary Embolism Risk Stratification and Clinical Outcomes

Among patients with acute pulmonary embolism (PE), abnormal cardiac biomarkers and elevated right ventricular to left ventricular (RV/LV) diameter ratio are associated with increased morbidity and mortality. However, subjects with baseline heart failure (HF) have abnormalities in cardiac chamber dimensions and biomarkers. We sought to describe risk stratification variables in a cohort with acute PE and categorized HF status as no HF, HF with reduced ejection fraction (HFrEF), or HF with preserved ejection fraction (HFpEF). In total, 182 subjects were identified for this study, of whom 142 were categorized as having no HF, 16 as having HFrEF, and 24 as having HFpEF. The median age was 65 years [interquartile range 51 to 75 years], and 43% were male. Subjects with HFrEF had significantly greater LV diameters and significantly lower RV/LV diameter ratio (no HF 0.94, HFrEF 0.65, HFpEF 0.89, p=0.002). Subjects with HFrEF also had significantly higher B-type natriuretic peptide levels (no HF 112 pg/mL, HFrEF 835 pg/mL, HFpEF 241 pg/mL, p <0.001) and higher 90-day mortality rates. Among subjects with acute PE, those with baseline HFrEF had significantly greater LV diameter and lower RV/LV diameter ratio than those of patients with HFpEF or no HF. In addition, subjects with HFrEF had significantly higher B-type natriuretic peptide levels and worse survival at 90days. In conclusion, these results indicate that PE risk stratification using current guidelines, especially reliance on RV/LV ratio, is inaccurate among subjects with baseline HFrEF.

Venous Thromboembolism Management in Pregnant Patients

Pulmonary embolism (PE) in pregnancy accounts for 10% of maternal deaths in the United States. As maternal morbidity and mortality continue to increase, it is imperative for all specialties interfacing with pregnant patients to understand the current research and guidelines surrounding risk stratification, diagnosis, and treatments of PE in pregnancy. Given the complexity of high-risk pregnancy-associated PE (PA-PE), that is, which is associated with hemodynamic instability or collapse, and the rising popularity of new technologies to treat high-risk PA-PE in the nonpregnant population, this review aims to emphasize the differences in diagnosis, risk stratification, and management of the pregnant and nonpregnant PE patients. Furthermore, this review will cover treatment paradigms that include anticoagulation versus advanced therapies such as systemic thrombolysis, surgical embolectomy, extracorporeal membrane oxygenation, and inferior vena cava disruption as well as the more novel therapies which fall under the umbrella term of catheter-based treatments. Finally, this review will include a case-based review of 2 patients with PA-PE requiring catheter-based therapies and their ultimate clinical outcomes.

Comparing predictive performance of pulmonary embolism risk stratification tools for acute clinical deterioration.

Existing pulmonary embolism (PE) risk scores were developed to predict death within weeks, but not more proximate adverse events. We determined the ability of 3 PE risk stratification tools (simplified pulmonary embolism severity index [sPESI], 2019 European Society of Cardiology guidelines [ESC], and PE short-term clinical outcomes risk estimation [PE-SCORE]) to predict 5-day clinical deterioration after emergency department (ED) diagnosis of PE. We analyzed data from six EDs on ED patients with confirmed PE. Clinical deterioration was defined as death, respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension requiring vasopressors or volume resuscitation, or escalated intervention within 5 days of PE diagnosis. We determined sensitivity and specificity of sPESI, ESC, and PE-SCORE for predicting clinical deterioration. Of 1569 patients, 24.5% had clinical deterioration within 5 days. sPESI, ESC, and PE-SCORE classifications were low-risk in 558 (35.6%), 167 (10.6%), and 309 (19.6%), respectively. Sensitivities of sPESI, ESC, and PE-SCORE for clinical deterioration were 81.8 (78, 85.7), 98.7 (97.6, 99.8), and 96.1 (94.2, 98), respectively. Specificities of sPESI, ESC, and PE-SCORE for clinical deterioration were 41.2 (38.4, 44), 13.7 (11.7, 15.6), and 24.8 (22.4, 27.3). Areas under the curve were 61.5 (59.1, 63.9), 56.2 (55.1, 57.3), and 60.5 (58.9, 62.0). Negative predictive values were 87.5 (84.7, 90.2), 97 (94.4, 99.6), and 95.1 (92.7, 97.5). ESC and PE-SCORE were better than sPESI for detecting clinical deterioration within 5 days after PE diagnosis.

Multimodal fusion models for pulmonary embolism mortality prediction

Pulmonary embolism (PE) is a common, life threatening cardiovascular emergency. Risk stratification is one of the core principles of acute PE management and determines the choice of diagnostic and therapeutic strategies. In routine clinical practice, clinicians rely on the patient’s electronic health record (EHR) to provide a context for their medical imaging interpretation. Most deep learning models for radiology applications only consider pixel-value information without the clinical context. Only a few integrate both clinical and imaging data. In this work, we develop and compare multimodal fusion models that can utilize multimodal data by combining both volumetric pixel data and clinical patient data for automatic risk stratification of PE. Our best performing model is an intermediate fusion model that incorporates both bilinear attention and TabNet, and can be trained in an end-to-end manner. The results show that multimodality boosts performance by up to 14% with an area under the curve (AUC) of 0.96 for assessing PE severity, with a sensitivity of 90% and specificity of 94%, thus pointing to the value of using multimodal data to automatically assess PE severity.