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Patients with acute pulmonary embolism at intermediate risk for death: Can we further stratify?

      International Scientific Societies (European Society of Cardiology, American Heart Association, American College of Chest Physician) recommend stratification for the risk of short-term death to drive acute clinical care in patients with acute pulmonary embolism (PE) [
      • Konstantinides S.V.
      • Torbicki A.
      • Agnelli G.
      • Authors/Task Force Members
      • et al.
      2014 ESC 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) Endorsed by the European Respiratory Society (ERS).
      ,
      • Jaff M.R.
      • McMurtry M.S.
      • Archer S.L.
      • et al.
      Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.
      ,
      • Kearon C.
      • Akl E.A.
      • Ornelas J.
      • et al.
      Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report.
      ]. However, no consensus exists on the optimal strategy for risk stratification beyond the classification in hemodynamically stable and unstable patients. The European Society of Cardiology (ESC) proposed a comprehensive strategy for risk stratification that includes both clinical and instrumental criteria [
      • Konstantinides S.V.
      • Torbicki A.
      • Agnelli G.
      • Authors/Task Force Members
      • et al.
      2014 ESC 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) Endorsed by the European Respiratory Society (ERS).
      ]. Based on this strategy, patients are divided by the ESC into three categories: low (1.2%), intermediate (3.4 to 10%) or high (15 to 30%) risk for death. To qualify for the intermediate-risk group, hemodynamically stable patients should have a not-low risk for death according to PESI or simplified PESI scores [
      • Konstantinides S.V.
      • Torbicki A.
      • Agnelli G.
      • Authors/Task Force Members
      • et al.
      2014 ESC 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) Endorsed by the European Respiratory Society (ERS).
      ]. This intermediate-risk group includes about 60% of patients with acute PE who can be highly heterogeneous concerning clinical features and the severity of PE [
      • Becattini C.
      • Agnelli G.
      • Lankeit M.
      • et al.
      Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model.
      ,
      • Becattini C.
      • Casazza F.
      • Forgione C.
      • et al.
      Acute pulmonary embolism: external validation of an integrated risk stratification model.
      ]. The ESC guidelines suggest to further classify the intermediate category into intermediate-low and intermediate-high risk of death according to the presence/absence of right ventricle dysfunction assessed by echocardiography or CTPA and/or by the presence/absence of increase in troponin levels (Table 1) [
      • Konstantinides S.V.
      • Torbicki A.
      • Agnelli G.
      • Authors/Task Force Members
      • et al.
      2014 ESC 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) Endorsed by the European Respiratory Society (ERS).
      ]. The aim of this stratification is the prompt identification of hemodynamically stable patients with expected short-term mortality of about 7 to 10% that could benefit from pulmonary reperfusion. In fact, according to the ESC guidelines, intermediate-high risk patients are candidates to initial monitoring and rescue reperfusion in case of clinical deterioration. An international cohort study showed that the sub-stratification of intermediate-risk patients (intermediate-high and intermediate-low) according to the ESC guidelines is probably not efficient in discriminating two categories of patients at different risk of death and requires improvement [
      • Becattini C.
      • Agnelli G.
      • Lankeit M.
      • et al.
      Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model.
      ].
      Table 1Risk stratification in hemodynamically stable patients with acute PE according to different scores or models [
      • Beigel R.
      • Mazin I.
      • Goitein O.
      • et al.
      Intermediate-risk pulmonary embolism: aiming to improve patient stratification.
      ,
      • Becattini C.
      • Vedovati M.C.
      • Pruszczyk P.
      • et al.
      Oxygen saturation or respiratory rate to improve risk stratification in hemodynamically stable patients with acute pulmonary embolism.
      ,
      • Bova C.
      • Vanni S.
      • Prandoni P.
      • Bova Score Validation Study Investigators
      • et al.
      A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism.
      ,
      • Dellas C.
      • Tschepe M.
      • Seeber V.
      • et al.
      A novel H-FABP assay and a fast prognostic score for risk assessment of normotensive pulmonary embolism.
      ,
      • Kochmareva E.A.
      • Kokorin V.A.
      • Gordeev I.G.
      The new bedside ROCky score to predict the complications in patients with intermediate-risk pulmonary embolism.
      ,
      • Vanni S.
      • Jiménez D.
      • Nazerian P.
      • et al.
      Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate.
      ].
      Model Composition
      Validated Models 2014 ESC RVD+ increased troponin
      RVD or increased troponin or none
      Low risk: simplified PESI = 0 or PESI class I or II
      Bova score sBP 90-100 mmHg +2
      Heart Rate ≥ 110 bpm +1
      RVD +2
      Increased troponin +2
      Telos RVD + Increased troponin+increased lactate
      RVD + Increased troponin
      RVD or Increased troponin or none
      FAST Syncope 1.5
      Heart rate ≥ 100 bpm 2
      H-FABP ≥6 ng/ml or elevated troponin 1.5
      Non validated Models 2014 ESC + OXYGEN SATURATION RVD+ increased troponin + oxygen saturation < 88%
      RVD or increased troponin + oxygen saturation < 88%
      RVD or increased troponin
      Low risk: simplified PESI = 0 or PESI class I or II
      ROCky score Positive hFABP test +2
      Heart rate ≥ 110 bpm +1.5
      Diabetes mellitus +2.5
      sBP ≤ 100 mmHg +2.5
      Low risk: simplified PESI = 0 or PESI class I or II
      Beigel et al Syncope +1
      Moderate or severe RVD on echocardiography +1
      RV/LV ratio above >1.425 on CT tomography +1
      Troponin in the upper tertile (>0.7 μg/l) +1
      Normal ECG -1
      Low risk: simplified PESI = 0 or PESI class I or II
      RVD = Right Ventricle Dysfunction; bpm: beats per minute; hFABP: heart-type Fatty Acid Binding Peptide; PESI = Pulmonary Embolism Severity Index; sBP = systolic Blood Pressure.
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      References

        • Konstantinides S.V.
        • Torbicki A.
        • Agnelli G.
        • Authors/Task Force Members
        • et al.
        2014 ESC 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) Endorsed by the European Respiratory Society (ERS).
        Eur Heart J. 2014; 35: 3033-3069
        • Jaff M.R.
        • McMurtry M.S.
        • Archer S.L.
        • et al.
        Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.
        Circulation. 2011; 123: 1788-1830
        • Kearon C.
        • Akl E.A.
        • Ornelas J.
        • et al.
        Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report.
        Chest. 2016; 149: 315-352
        • Becattini C.
        • Agnelli G.
        • Lankeit M.
        • et al.
        Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model.
        Eur Respir J. 2016; 48: 780-786
        • Becattini C.
        • Casazza F.
        • Forgione C.
        • et al.
        Acute pulmonary embolism: external validation of an integrated risk stratification model.
        Chest. 2013; 144: 1539-1545
        • Beigel R.
        • Mazin I.
        • Goitein O.
        • et al.
        Intermediate-risk pulmonary embolism: aiming to improve patient stratification.
        Eur J Intern Med. 2019 May 1; https://doi.org/10.1016/j.ejim.2019.04.018
        • Becattini C.
        • Vedovati M.C.
        • Pruszczyk P.
        • et al.
        Oxygen saturation or respiratory rate to improve risk stratification in hemodynamically stable patients with acute pulmonary embolism.
        J Thromb Haemost. 2018; 16: 2397-2402
        • Bova C.
        • Vanni S.
        • Prandoni P.
        • Bova Score Validation Study Investigators
        • et al.
        A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism.
        Thromb Res. 2018; 165: 107-111
        • Dellas C.
        • Tschepe M.
        • Seeber V.
        • et al.
        A novel H-FABP assay and a fast prognostic score for risk assessment of normotensive pulmonary embolism.
        Thromb Haemost. 2014; 111: 996-1003
        • Kochmareva E.A.
        • Kokorin V.A.
        • Gordeev I.G.
        The new bedside ROCky score to predict the complications in patients with intermediate-risk pulmonary embolism.
        Eur J Intern Med. 2018; 57: 58-60
        • Vanni S.
        • Jiménez D.
        • Nazerian P.
        • et al.
        Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate.
        Thorax. 2015; 70: 333-338
        • Becattini C.
        • Agnelli G.
        • Germini F.
        • Vedovati M.C.
        Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis.
        Eur Respir J. 2014; 43: 1678-1690
        • Sanchez O.
        • Trinquart L.
        • Caille V.
        • et al.
        Prognostic factors for pulmonary embolism: the PREP study, a prospective multicenter cohort study.
        Am J Respir Crit Care Med. 2010; 181: 168-173
        • Barco S.
        • Ende-Verhaar Y.M.
        • Becattini C.
        • et al.
        Differential impact of syncope on the prognosis of patients with acute pulmonary embolism: a systematic review and meta-analysis.
        Eur Heart J. 2018; 39: 4186-4195
        • Girard P.
        • Penaloza A.
        • Parent F.
        • et al.
        Reproducibility of clinical events adjudications in a trial of venous thromboembolism prevention.
        J Thromb Haemost. 2017; 15: 662-669
        • Stuck A.K.
        • Fuhrer E.
        • Limacher A.
        • Méan M.
        • Aujesky D.
        Adjudication-related processes are underreported and lack standardization in clinical trials of venous thromboembolism: a systematic review.
        J Clin Epidemiol. 2014; 67: 278-284
        • Meyer G.
        • Vicaut E.
        • Danays T.
        • PEITHO Investigators
        • et al.
        Fibrinolysis for patients with intermediate-risk pulmonary embolism.
        N Engl J Med. 2014; 370: 1402-1411

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