Validation of the Predictive Model of the European Society of Cardiology for Early Mortality in Acute Pulmonary Embolism

The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis

Introduction

Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram.

Method

This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality.

Results

Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality.

Conclusion

Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.

The timing of death in acute pulmonary embolism patients regarding the mortality risk stratification at admission to the hospital

Background

The management of patients with acute pulmonary embolism (aPE) depends on the severity of aPE. The timing of death in various aPE risk subgroups is only partially known.

Methods

1618 patients with an objectively established aPE diagnosis with computed tomography pulmonary angiography enrolled in the regional PE registry were included in the study. According to ESC criteria, patients were stratified at admission to the hospital in four risk strata. The timing of PE-related and non-PE-related deaths was analyzed regarding mortality risk.

Results

PE-related, and non-PE-related hospital death rates were 1.1 % and 1.5 % in low, 1.1 % and 4.8 % in intermediate-low, 8.1 % and 5.9 % in intermediate-high, and 27.7 % and 6.9 % in high-risk groups, respectively. The median time of PE-related and non-PE-related death across the PE mortality risk were: 4 (1.7-7.5) and 7.0 (4-14.7) days in low, 1.5 (1.0-9.5) and 11.5 (2.0-21.0) days in intermediate-low, 4.0 (2.0-9.0) and 9.0 (5.7-18.2) days in intermediate-high, 2.0 (1.0-4.75) and 7.0 (3.0-21.2) days in high-risk subgroups. 48.2 % and 17.1 % of patients who died in the high and intermediate-high risks died during the first hospital day. After the 6th hospitalization day, PE-related deaths were recorded in 43.9 % of deaths from intermediate-high and 17.9 % from high-risk subgroups.

Conclusion

PE-related mortality is prominent on the first hospitalization day in high and intermediate-high-risk PE. A substantial proportion of intermediate-high and high-risk patient's PE deaths occurred after the first 6 days of hospitalization.

Machine learning-based models for predicting mortality and acute kidney injury in critical pulmonary embolism

OBJECTIVES

We aimed to use machine learning (ML) algorithms to risk stratify the prognosis of critical pulmonary embolism (PE).

MATERIAL AND METHODS

In total, 1229 patients were obtained from MIMIC-IV database. Main outcomes were set as all-cause mortality within 30 days. Logistic regression (LR) and simplified eXtreme gradient boosting (XGBoost) were applied for model constructions. We chose the final models based on their matching degree with data. To simplify the model and increase its usefulness, finally simplified models were built based on the most important 8 variables. Discrimination and calibration were exploited to evaluate the prediction ability. We stratified the risk groups based on risk estimate deciles.

RESULTS

The simplified XGB model performed better in model discrimination, which AUC were 0.82 (95% CI: 0.78-0.87) in the validation cohort, compared with the AUC of simplified LR model (0.75 [95% CI: 0.69-0.80]). And XGB performed better than sPESI in the validation cohort. A new risk-classification based on XGB could accurately predict low-risk of mortality, and had high consistency with acknowledged risk scores.

CONCLUSIONS

ML models can accurately predict the 30-day mortality of critical PE patients, which could further be used to reduce the burden of ICU stay, decrease the mortality and improve the quality of life for critical PE patients.

Modified model for end-stage liver disease score predicts 30-day mortality in high-risk patients with acute pulmonary embolism admitted to intensive care units

OBJECTIVES

The Model for End-stage Liver Disease excluding the international normalised ratio that is derived from prothrombin time which is calculated as a ratio of the patient's prothrombin time to a control prothrombin time standardized (MELD-XI) and modified MELD, which uses albumin in place of the international normalised ratio (MELD-Albumin) scores reflect liver and renal function and are predictors of mortality. However, their prognostic value in acute pulmonary embolism (APE) has not been studied.

DESIGN

We assessed the predictive value of the MELD scores in patients diagnosed with high-risk APE admitted to the intensive care unit. The primary outcome was 30-day mortality.

RESULTS

Of the 273 patients included in the study, 231 were survivors and 42 were non-survivors. The mortality rate was 15.3%. The mean MELD-XI and MELD-Albumin scores were significantly higher in the non-survivors than in the survivors (MELD XI, 11.8 ± 1.8 and 10.6 ± 1.43, respectively; p = .002; MELD-Albumin, 10.5 ± 1.6 and 8.7 ± 1.1, respectively; p = .001). The multiple logistic regression analysis identified the MELD-XI (hazard ratio: 3.029, confidence interval: 1.06-1.21, p = .007) and MELD-Albumin (hazard ratio: 1.13, confidence interval: 1.06-1.21, p = .002) scores as independent predictors of mortality. Receiver operating characteristic analysis revealed that the predictive power of the MELD-Albumin score (0.871 ± 0.014; p < .001) was higher than those of the MELD-XI (0.726 ± 0.022, p < .001), APACHE III (0.682 ± 0.024, p < .001), and PESI (0.624 ± 0.023, p < .001) scores.

CONCLUSIONS

The MELD-Albumin score is an easily calculable, reliable, and practical risk assessment tool and independent predictor of 30-day mortality in patients with high-risk APE.

Home treatment of venous thromboembolism disease

Despite the potential benefits of outpatient care, most patients with pulmonary embolisms are treated in hospitals for fear of possible adverse events. However, there is a wealth of scientific evidence from studies covering more than 4000 outpatients, which has led the current clinical practice guidelines to recommend early discharge or outpatient treatment when a low risk of death or complications has been confirmed, when there are no comorbidities or aggravating processes present to warrant hospitalisation and when appropriate monitoring and treatment are observed. This approach minimises the complications that can arise in hospitals and represents considerable cost savings. When selecting these patients, the use of prognostic tools such as the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI) and the Hestia Criteria are of paramount importance. Using these tools, the short-term outcomes (30-90days) show low mortality (in general <3%) and a low incidence of other complications (rate of recurrence and major bleeding <2%). Based on the available evidence, outpatient treatment can be considered the most appropriate strategy at this time for most hemodynamically stable patients with pulmonary embolisms.

Assessment of the Bova score for risk stratification of acute normotensive pulmonary embolism: A systematic review and meta-analysis

BACKGROUND

Identification of normotensive pulmonary embolism (PE) at high risk of early adverse outcome is crucial for guiding treatment. Studies showed the Bova score had promising performance in stratifying normotensive PE.

METHODS

We conducted a systematic review and meta-analysis to evaluate the prognostic performance of the Bova score for normotensive PE.

RESULTS

Nine studies involving 8342 acute normotensive PE patients were enrolled. Overall, 71.4%, 20.2% and 8.4% patients were stratified as risk class I, II and III. Pooled incidence of short-term PE related composite adverse outcome of each group were 3.8%, 10.8% and 19.9%, respectively, exhibiting a significant rising trend. Increasing trends of 30-day and in-hospital composite adverse outcome rates, as well as PE related mortality, were also observed with upper risk classes. Compared with risk class I and II, high risk group (class III) was significantly associated with short-term PE related composite adverse outcome (OR: 5.45, 95% CI, 3.70-8.02) and PE related death (OR: 5.09, 95% CI, 3.54-7.30). Pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the score for predicting short-term composite adverse outcome were 0.25 (95% CI, 0.22-0.29), 0.93 (95% CI, 0.92-0.93), 4.05 (95% CI, 2.90-5.67) and 0.81 (95% CI, 0.74-0.88), respectively. The weighted area under the summarized receiver characteristics operation curve for predicting composite adverse outcome was 0.73 ± 0.09.

CONCLUSION

The Bova score could effectively discriminate normotensive PE with different short-term prognosis and has good performance in identifying patients at higher risk of short-term adverse events.