Tools Flag Need for Intensive Care in PE Patients
NEW ORLEANS — The best predictors of in-hospital deterioration of patients diagnosed with acute pulmonary embolism are a shock index greater than 1 and a pulmonary embolism severity index score more than 100, according to data from the EMPEROR registry.
In patients with pulmonary embolism, routinely calculate the pulmonary embolism severity index (PESI) and shock index, and strongly consider admission to an ICU for patients with elevated values, Dr. Jeffrey A. Kline advised at the annual meeting of the Society for Academic Emergency Medicine.
He analyzed data on in-hospital adverse events in 2,188 consecutive patients diagnosed with pulmonary embolism in 22 emergency departments in the landmark EMPEROR (Emergency Medicine Pulmonary Embolism in the Real World Registry) study, the first-ever large multicenter prospective observational study of pulmonary embolism in the United States.
Five predictors were selected for study inclusion: oxygen saturation (SaO2) below 95%, an abnormal serum troponin level, a brain natriuretic peptide level greater than 90 pg/mL or pro-brain natriuretic peptide level in excess of 900 pg/mL, a shock index greater than 1, and a PESI score greater than 100, said Dr. Kline, director of research in the department of emergency medicine at Carolinas Medical Center, Charlotte, N.C.
PESI factors include age greater than 65 years, male sex, and comorbid cancer, chronic pulmonary disease, or heart failure (Am. J. Respir. Crit. Care Med. 2005;172:1,041–6).
In the EMPEROR study, death from pulmonary embolism, shock requiring vasopressors, intubation, or surgical embolectomy occurred in 3.5% of the patients. Nearly all of the adverse events happened within 48 hours; roughly two-thirds occurred within 24 hours. Death from pulmonary embolism occurred in only 0.9% of EMPEROR participants.
None of the predictors displayed good sensitivity for predicting adverse events. However, a PESI greater than 100 had outstanding specificity and conferred an 8.7-fold increased likelihood of adverse outcome. The shock index performed second best. The two vital signs proved to be slightly better predictors than the two biomarkers.
An upgrade to the ICU occurred in 1.5% of patients within 24 hours after their admission to a hospital bed.
Audience members said that they are under pressure from hospital administrators to identify patients with pulmonary embolism who can safely be discharged home. They asked whether any of the five predictors were useful for that purpose.
Dr. Kline replied that he has not looked at the EMPEROR data toward that end. However, he is aware of ongoing European studies that suggest a PESI score lower than 50 or so shows potential for such a purpose.
EMPEROR was funded in part by GlaxoSmithKline.
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