Accuracy of an integrated approach including clinical, analytical and imaging parameters for prognostication in hospitalized patients with acute pulmonary embolism
Authors: Duarte F , Oliveira L , Santos I , Monteiro A , Machado C , Dourado R , Martins D 
Published: June 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Acute pulmonary thromboembolism (PE) is a life-threatening condition and an early diagnosis and adequate therapy are critical. Mortality in PE still remains very high in spite of progress in diagnostic tools. Several parameters for risk stratification have been reported with a variable importance on clinical practice.

Purpose
To compare the performance of different parameters (clinical, analytical and imaging parameters) in predicting adverse in-hospital events in acute PE.

Methods
We retrospectively assessed consecutive patients from a single center registry who were hospitalized due to an acute PE. Four different parameters were determined: Clinical and echocardiographic (PESI class and PESI-Echo score), analytical (lactate and troponin I admission values) and anatomical imaging (central or peripheral thrombi location) parameters. A composite outcome of adverse in-hospital events (including cardiogenic shock, acute respiratory failure, severe bleeding events or in-hospital mortality) was determined. Discriminative power of each parameter was assessed by receiver operating characteristic curve analysis.

Results
A total of 131 patients (mean age of 67.6 ± 15.3 years-old, female 71%) were included. Regarding baseline comorbidities, 63.4% of the patients had hypertension, 27.4% had a recent hospitalization or major surgery and 19.8% had a medical history of active. Besides anticoagulation, 7 patients (5.3%) underwent fibrinolysis. Overall in-hospital mortality was 8.4% and 3.8% of the patients had a severe bleeding event, respiratory failure or cardiogenic shock.
According to the PESI classification, 29.8% of the patients were included in class V, 26.7% in class III and 17.6% in class II. PESI classification had a weak positive correlation with the outcome (p&lt;0.001; r=0.37), like PESI-Echo score (p = 0.018; r=0.36). Attending to in-hospital adverse events, 72.2% occurred in PESI class V patients (p = 0.020). Both analytical parameters (lactate and troponin I) determined at hospital admission had a good discriminative power in predicting the composite in-hospital outcome. Discriminative power was superior for lactate and troponin I (AUC 0.864, 95% CI 2.8 – 187; p &lt;0.001) vs imaging data (AUC 0.64, p = 0.12).
Comparing all-four parameters, PESI-Echo score had the best discriminative power (AUC 1.0, p = 0.008), followed by PESI class (AUC 0.925) and lactate value at hospital admission (AUC 0.856). The cut-off value for PESI-Echo was 211.

Conclusion
These results highlight the prognostic value of the addition of echocardiographic parameters to usual scores for risk stratification. In our cohort of patients, PESI-Echo score showed overall good performance in stratifying in-hospital adverse events. Its application in clinical practice as an additional risk stratification tool could be of interest.