Risk stratifying emergency department patients with acute pulmonary embolism: Does the simplified Pulmonary Embolism Severity Index perform as well as the original?

Vinson, David R; Ballard, Dustin W; Mark, Dustin G; Huang, Jie; Reed, Mary E; Rauchwerger, Adina S; Wang, David H; Lin, James S; Kene, Mamata V; Pleshakov, Tamara S; Sax, Dana K; Sax, Jordan M; McLachlan, D Ian; Yamin, Cyrus K; Swap, Clifford J; Iskin, Hilary R; Vemula, Ridhima; Fleming, Bethany S; Elms, Andrew R and Aujesky, Drahomir (2016). Risk stratifying emergency department patients with acute pulmonary embolism: Does the simplified Pulmonary Embolism Severity Index perform as well as the original? Thrombosis research, 148, pp. 1-8. Elsevier 10.1016/j.thromres.2016.09.023

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INTRODUCTION

The Pulmonary Embolism Severity Index (PESI) is a validated prognostic score to estimate the 30-day mortality of emergency department (ED) patients with acute pulmonary embolism (PE). A simplified version (sPESI) was derived but has not been as well studied in the U.S. We sought to validate both indices in a community hospital setting in the U.S. and compare their performance in predicting 30-day all-cause mortality and classification of cases into low-risk and higher-risk categories.

MATERIALS AND METHODS

This retrospective cohort study included adults with acute objectively confirmed PE from 1/2013 to 4/2015 across 21 community EDs. We evaluated the misclassification rate of the sPESI compared with the PESI. We assessed accuracy of both indices with regard to 30-day mortality.

RESULTS

Among 3006 cases of acute PE, the 30-day all-cause mortality rate was 4.4%. The sPESI performed as well as the PESI in identifying low-risk patients: both had similar sensitivities, negative predictive values, and negative likelihood ratios. The sPESI, however, classified a smaller proportion of patients as low risk than the PESI (27.5% vs. 41.0%), but with similar low-risk mortality rates (<1%). Compared with the PESI, the sPESI overclassified 443 low-risk patients (14.7%) as higher risk, yet their 30-day mortality was 0.7%. The sPESI underclassified 100 higher-risk patients (3.3%) as low risk who also had a low mortality rate (1.0%).

CONCLUSIONS

Both indices identified patients with PE who were at low risk for 30-day mortality. The sPESI, however, misclassified a significant number of low-mortality patients as higher risk, which could lead to unnecessary hospitalizations.

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