Advertisement

Internal and Emergency Medicine

, Volume 12, Issue 5, pp 657–665 | Cite as

Comparison of clinical scores for identification of patients with pulmonary embolism at intermediate–high risk of adverse clinical outcome: the prognostic role of plasma lactate

  • Simone VanniEmail author
  • Peiman Nazerian
  • Carlo Bova
  • Ernesta Bondi
  • Fulvio Morello
  • Giuseppe Pepe
  • Barbara Paladini
  • Giovanni Liedl
  • Elisabetta Cangioli
  • Stefano Grifoni
  • David Jiménez
EM - ORIGINAL

Abstract

To compare the prognostic accuracy of the 2014 risk model of the European Society of Cardiology (ESC) and of Bova and TELOS scores for identification of normotensive patients with pulmonary embolism (PE) at high risk for short-term adverse events (i.e., intermediate–high risk patients), we retrospectively applied these tests to a prospective cohort of 994 normotensive patients with objectively confirmed PE. Sixty-three (6.3 %) patients reached the primary outcome, a composite of hemodynamic collapse and death within 7 days from diagnosis. The Bova and TELOS scores classified the same proportion of patients in intermediate–high risk category (5.9 and 5.7 %, respectively), with a similar primary outcome rate (18.6 and 21.1 %, respectively). The 2014 ESC model classified in the intermediate–high risk category the largest proportion of patients (12.5 %, p < 0.001 vs Bova and TELOS), with the lowest primary outcome rate (13 %, p = ns vs Bova and TELOS). When lactate determination was added to the Bova score, 112 patients (11.2 %) were classified in the intermediate–high risk category (p < 0.05 vs Bova and TELOS), with a slight increase in the primary outcome rate (25.9 %, p = 0.014 vs 2014 ESC model), allowing the recognition of a twofold higher number of patients reaching the primary outcome (29 vs 15, 11 and 12 patients in the 2014 ESC model, Bova and TELOS scores, respectively, p < 0.01 for all). The 2014 ESC model, Bova and TELOS scores identify a small number of intermediate–high risk patients with PE, without differences among tests. Adding plasma lactate to the Bova score significantly improves the identification of intermediate–high risk patients.

Keywords

Pulmonary embolism Troponin Right ventricular dysfunction Lactate Prognosis 

Abbreviations

CI

Confidence interval

ESC

European Society of Cardiology

HR

Heart rate

IQR

Inter-quartile rage

PE

Pulmonary embolism

PESI

Pulmonary Embolism Severity Index

RV

Right ventricular

SBP

Systolic blood pressure

SD

Standard deviation

sPESI

Simplified Pulmonary Embolism Severity Index

TELOS

Thrombo-embolism lactate outcome study

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

The study was approved by the Istitutional Review Board.

Informed consent

Written informed consent was obtained for inclusion in each study.

References

  1. 1.
    Grifoni S, Olivotto I, Cecchini P et al (2000) Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 101:2817–2822CrossRefPubMedGoogle Scholar
  2. 2.
    Binder L, Pieske B, Olschewski M, Geibel A, Klostermann B, Reiner C, Konstantinides S (2005) N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 112(11):1573–1579CrossRefPubMedGoogle Scholar
  3. 3.
    Pieralli F, Olivotto I, Vanni S, Conti A, Camaiti A, Targioni G, Grifoni S, Berni G (2006) Usefulness of bedside testing for brain natriuretic peptide to identify right ventricular dysfunction and outcome in normotensive patients with acute pulmonary embolism. Am J Cardiol 97(9):1386–1390CrossRefPubMedGoogle Scholar
  4. 4.
    Becattini C, Vedovati MC, Agnelli G (2007) Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 116(4):427–433CrossRefPubMedGoogle Scholar
  5. 5.
    Meyer G, Vicaut E, Danays T et al (2014) PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 370:1402–1411CrossRefPubMedGoogle Scholar
  6. 6.
    Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, Roy PM, Fine MJ (2005) Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 172(8):1041–1046CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Jiménez D, Aujesky D, Moores L et al. (2010) Simplification of the Pulmonary Embolism Severity Index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 170:1383–1389CrossRefPubMedGoogle Scholar
  8. 8.
    Konstantinides SV, Torbicki A, Agnelli G et al (2014) Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology. Eur Heart J 35:3033–3080CrossRefPubMedGoogle Scholar
  9. 9.
    Becattini C, Agnelli G, Lankeit M et al (2016) Acute pulmonary embolism: external validation of the 2014 risk stratification model of the European Society of Cardiology. Eur Resp J [Epub ahead of print] PMID:27174887Google Scholar
  10. 10.
    Bova C, Sanchez O, Prandoni P et al (2014) Identification of intermediate-risk patients with acute symptomatic pulmonary embolism. Eur Respir J 44:694–703CrossRefPubMedGoogle Scholar
  11. 11.
    Fernàndez C, Bova C, Sanchez O et al (2015) Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism. Chest 148:211–218CrossRefPubMedGoogle Scholar
  12. 12.
    Jones AE, Shapiro NI, Trzeciak S et al (2010) Emergency Medicine Shock Research Network (EMShockNet) Investigators: Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA 303:739–746CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Lavery RF, Livingston DH, Tortella BJ et al (2000) The utility of venous lactate to triage injured patients in the trauma center. J Am Coll Surg 190:656–664CrossRefPubMedGoogle Scholar
  14. 14.
    Vanni S, Viviani G, Baioni M et al (2013) Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Ann Emerg Med 61:330–338CrossRefPubMedGoogle Scholar
  15. 15.
    Vanni S, Socci F, Pepe G et al (2011) High plasma lactate levels are associated with increased risk of in-hospital mortality in patients with pulmonary embolism. Acad Emerg Med 18:830–835CrossRefPubMedGoogle Scholar
  16. 16.
    Vanni S, Jimènez D, Nazerian P et al (2015) Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate. Thorax 70:333–338CrossRefPubMedGoogle Scholar
  17. 17.
    Vanni S, Polidori G, Vergara R et al (2009) Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure. Am J Med 122:257–264CrossRefPubMedGoogle Scholar
  18. 18.
    Hosmer DW, Lemeshow S (2000) Applied logistic regression, 2nd edn. John Wiley & Sons Inc, New YorkCrossRefGoogle Scholar
  19. 19.
    Efron B, Tibshirani RJ (1998) An introduction to the bootstrap. Chapman & Hall/CRC Press, New YorkGoogle Scholar
  20. 20.
    Steyerberg EW, Harrell FE Jr, Borsboom GJ et al (2001) Internal validation of predictive models. J Clin Epidemiol 54:774–781CrossRefPubMedGoogle Scholar
  21. 21.
    Torbicki A, Perrier A, Konstantinides S et al (2008) ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 29:2276–2315CrossRefPubMedGoogle Scholar
  22. 22.
    Grifoni S, Vanni S, Magazzini S et al (2006) Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events. Arch Intern Med 166:2151–2156CrossRefPubMedGoogle Scholar
  23. 23.
    Kucher N, Goldhaber SZ (2003) Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation 108:2191–2194CrossRefPubMedGoogle Scholar
  24. 24.
    Jiménez D, Aujesky D, Moores L et al (2011) Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism. Thorax 66:75–81CrossRefPubMedGoogle Scholar
  25. 25.
    Vanni S, Nazerian P, Pepe G et al (2011) Comparison of two prognostic models for acute pulmonary embolism: clinical vs. right ventricular dysfunction-guided approach. J Thromb Haemost 9:1916–1923CrossRefPubMedGoogle Scholar
  26. 26.
    Lankeit M, Friesen D, Schafer K, Hasenfuß G, Konstantinides S, Dellas C (2013) A simple score for rapid risk assessment of non-high-risk pulmonary embolism. Clin Res Cardiol 102:73–80CrossRefPubMedGoogle Scholar
  27. 27.
    Jiménez D, Kopecna D, Tapson V et al (2014) PROTECT investigators. Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism. Am J Respir Crit Care Med 189:718–726CrossRefPubMedGoogle Scholar
  28. 28.
    Sanchez O, Trinquart L, Planquette B et al (2013) Echocardiography and Pulmonary Embolism Severity Index have independent prognostic roles in pulmonary embolism. Eur Respir J 42:681–688CrossRefPubMedGoogle Scholar
  29. 29.
    Vedovati MC, Becattini C, Agnelli G, Kamphuisen PW, Masotti L, Pruszczyk P, Casazza F, Salvi A, Grifoni S, Carugati A, Konstantinides S, Schreuder M, Golebiowski M, Duranti M (2012) Multidetector CT scan for acute pulmonary embolism: embolic burden and clinical outcome. Chest 142:1417–1424CrossRefPubMedGoogle Scholar

Copyright information

© SIMI 2016

Authors and Affiliations

  • Simone Vanni
    • 1
    Email author
  • Peiman Nazerian
    • 1
  • Carlo Bova
    • 2
  • Ernesta Bondi
    • 1
  • Fulvio Morello
    • 3
  • Giuseppe Pepe
    • 1
  • Barbara Paladini
    • 1
  • Giovanni Liedl
    • 1
  • Elisabetta Cangioli
    • 1
  • Stefano Grifoni
    • 1
  • David Jiménez
    • 4
  1. 1.Emergency DepartmentAzienda Ospedaliero-Universitaria CareggiFlorenceItaly
  2. 2.Department of MedicineUniversity Hospital of CosenzaCosenzaItaly
  3. 3.Emergency DepartmentA.O.U. Città della Salute e della Scienza di TorinoTurinItaly
  4. 4.Respiratory Department, Ramón y Cajal Hospital, IRYCISAlcalá de Henares UniversityMadridSpain

Personalised recommendations