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) [
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).
Eur Heart J. 2014; 35: 3033-3069
2
,
3
]. 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 [
[1]
]. 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).
Eur Heart J. 2014; 35: 3033-3069
[1]
]. 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 [
- 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
[4]
,
[5]
]. 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) [
[1]
]. 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 [
- 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
[4]
].
Table 1Risk stratification in hemodynamically stable patients with acute PE according to
different scores or models [
6
,
- 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
7
,
8
,
9
,
10
,
11
].| 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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Published online: June 24, 2019
Received:
June 8,
2019
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© 2019 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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- Intermediate-risk pulmonary embolism: Aiming to improve patient stratificationEuropean Journal of Internal MedicineVol. 65
- PreviewIntermediate-risk pulmonary embolism (PE) patients present a therapeutic dilemma. While some are at risk for developing adverse events, possibly requiring escalation therapy, most will have a benign course. Our aim was to define predictors which will identify those patients who will not deteriorate despite the presence of RV involvement.
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