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Jiménez D. Pulmonary embolism: Put the sPESI into practice. Eur J Intern Med 2024; 124:40-41. [PMID: 38599925 DOI: 10.1016/j.ejim.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Affiliation(s)
- David Jiménez
- Respiratory Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
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2
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González S, Najarro M, Briceño W, Rodríguez C, Barrios D, Morillo R, Olavarría A, Lietor A, Gómez Del Olmo V, Osorio Á, Sánchez-Recalde Á, Muriel A, Jiménez D. Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism. Rev Clin Esp 2024; 224:141-149. [PMID: 38336141 DOI: 10.1016/j.rceng.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE. METHODS We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality. RESULTS Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE. CONCLUSIONS Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality.
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Affiliation(s)
- S González
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - M Najarro
- Servicio de Urgencias, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - W Briceño
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - C Rodríguez
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - D Barrios
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - R Morillo
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - A Olavarría
- Servicio de Radiología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - A Lietor
- Servicio de Medicina Intensiva, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - V Gómez Del Olmo
- Servicio de Medicina Interna, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Á Osorio
- Servicio de Cirugía Vascular, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Á Sánchez-Recalde
- Servicio de Cardiología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Servicio de Bioestadística, Hospital Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain
| | - D Jiménez
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Medicina, Universidad de Alcalá, Madrid, Spain.
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Hyder SN, Goraya SR, Grace KA, O'Hare C, Schaeffer WJ, Stover M, Matthews T, Khaja MS, Liles A, Greineder CF, Barnes GD. Prediction of in-hospital deterioration in normotensive pulmonary embolism remains elusive: external validation of the calgary acute pulmonary embolism score. J Thromb Thrombolysis 2023; 56:327-332. [PMID: 37351823 PMCID: PMC10641891 DOI: 10.1007/s11239-023-02853-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 06/24/2023]
Abstract
Acute pulmonary embolism (PE) is a frequently diagnosed condition. Prediction of in-hospital deterioration is challenging with current risk models. The Calgary Acute Pulmonary Embolism (CAPE) score was recently derived to predict in-hospital adverse PE outcomes but has not yet been externally validated. Retrospective cohort study of normotensive acute pulmonary embolism cases diagnosed in our emergency department between 2017 and 2019. An external validation of the CAPE score was performed in this population for prediction of in-hospital adverse outcomes and a secondary outcome of 30-day all-cause mortality. Performance of the simplified Pulmonary Embolism Severity Index (sPESI) and Bova score was also evaluated. 712 patients met inclusion and exclusion criteria, with 536 patients having a sPESI score of 1 or more. Among this population, the CAPE score had a weak discriminative power to predict in-hospital adverse outcomes, with a calculated c-statistic of 0.57. In this study population, an external validation study found weak discriminative power of the CAPE score to predict in-hospital adverse outcomes among normotensive PE patients. Further efforts are needed to define risk assessment models that can identify normotensive PE patients at risk for in hospital deterioration. Identification of such patients will better guide intensive care utilization and invasive procedural management of PE.
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Affiliation(s)
- S Nabeel Hyder
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, 2800 Plymouth Rd, B14 G214, Ann Arbor, MI, 48109-2800, USA
| | | | - Kelsey A Grace
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Connor O'Hare
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William J Schaeffer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael Stover
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Timothy Matthews
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General hospital, Harvard Medical School, Boston, MA, USA
| | - Minhaj S Khaja
- Department of Radiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Amber Liles
- Department of Radiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Colin F Greineder
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, 2800 Plymouth Rd, B14 G214, Ann Arbor, MI, 48109-2800, USA.
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Shiber J, Fontane E, Patel J, Akinleye A, Kerwin A, Chiu W, Scalea T. Gestalt clinical severity score (GCSS) as a predictor of patient severity of illness or injury. Am J Emerg Med 2023; 66:11-15. [PMID: 36640694 DOI: 10.1016/j.ajem.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/26/2022] [Accepted: 01/02/2023] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To determine if clinical judgement is accurate to predict the severity of injury or illness, and can be used at patient arrival when other formal scoring systems are not yet available. DESIGN A multicenter pilot study using a prospective observational convenience sample of patients arriving by EMS to the emergency department (ED) or Trauma Center. SETTING Two urban, Level 1 trauma centers at academic tertiary care hospitals. PATIENTS Medical and trauma patients age 18 and older transported by EMS (N = 216). Exclusion criteria (prior to arrival): intubation, assisted ventilation (BVM or NPPV), CPR in progress, prisoners, or previously present motor or speech deficits. MEASUREMENTS Completion of a novel 15-point scale of Verbal, Motor, and Facial Expression within 1-2 min of arrival by a clinician outside of the treatment team. Primary endpoint was the immediate disposition from the ED or Trauma Center: Home, Brief Observation (<24 h), Admission to Floor, ICU (OR and IR as surrogates since these patients ultimately go to the ICU), or Morgue. RESULTS Univariate analysis revealed a strong, positive monotonic correlation between GCSS and disposition (Rho = 0.693, p < .0001). Multivariable logistic regression revealed the "best" model included GCSS and age (group 18-44 years old versus all the other age groups) (p < .0001). There was a 156% increase in the odds of being discharged home (versus being admitted) for a one-unit increase in GCSS (OR = 2.56, 95% CI 1.94, 3.37). CONCLUSIONS Physicians can make accurate predictions of severity of injury and illness using a gestalt method and the scoring system we have developed as patient disposition correlates well with GCSS score. GCSS is most accurate with the 18-44 age group.
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Affiliation(s)
| | | | - Jignesh Patel
- Houston Methodist Hospital, Houston, TX, United States of America
| | | | - Andy Kerwin
- UT HSC, Memphis, TN, United States of America.
| | - William Chiu
- UMMS/R Adams Cowley STC, Baltimore, MD, United States of America.
| | - Thomas Scalea
- UMMS/R Adams Cowley STC, Baltimore, MD, United States of America.
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Barnes GD, Muzikansky A, Cameron S, Giri J, Heresi GA, Jaber W, Wood T, Todoran TM, Courtney DM, Tapson V, Kabrhel C. Comparison of 4 Acute Pulmonary Embolism Mortality Risk Scores in Patients Evaluated by Pulmonary Embolism Response Teams. JAMA Netw Open 2020; 3:e2010779. [PMID: 32845326 PMCID: PMC7450352 DOI: 10.1001/jamanetworkopen.2020.10779] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE The risk of death from acute pulmonary embolism can range as high as 15%, depending on patient factors at initial presentation. Acute treatment decisions are largely based on an estimate of this mortality risk. OBJECTIVE To assess the performance of risk assessment scores in a modern, US cohort of patients with acute pulmonary embolism. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study was conducted between October 2016 and October 2017 at 8 hospitals participating in the Pulmonary Embolism Response Team (PERT) Consortium registry. Included patients were adults who presented with acute pulmonary embolism and had sufficient information in the medical record to calculate risk scores. Data analysis was performed from March to May 2020. MAIN OUTCOMES AND MEASURES All-cause mortality (7- and 30-day) and associated discrimination were assessed by the area under the receiver operator curve (AUC). RESULTS Among 416 patients with acute pulmonary embolism (mean [SD] age, 61.3 [17.6] years; 207 men [49.8%]), 7-day mortality in the low-risk groups ranged from 1.3% (1 patient) to 3.1% (4 patients), whereas 30-day mortality ranged from 2.6% (1 patient) to 10.2% (13 patients). Among patients in the highest-risk groups, the 7-day mortality ranged from 7.0% (18 patients) to 16.3% (7 patients), whereas 30-day mortality ranged from 14.4% (37 patients) to 26.3% (26 patients). Each of the risk stratification tools had modest discrimination for 7-day mortality (AUC range, 0.616-0.666) with slightly lower discrimination for 30-day mortality (AUC range, 0.550-0.694). CONCLUSIONS AND RELEVANCE These findings suggest that commonly used risk tools for acute pulmonary embolism have modest estimating ability. Future studies to develop and validate better risk assessment tools are needed.
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Affiliation(s)
- Geoffrey D. Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Scott Cameron
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jay Giri
- Department of Internal Medicine, University of Pennsylvania, Philadelphia
| | - Gustavo A. Heresi
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Wissam Jaber
- Division of Cardiology, Department of Internal Medicine, Emory University, Atlanta, Georgia
| | - Todd Wood
- Division of Cardiology, Department of Internal Medicine, Lancaster General Hospital, Lancaster, Pennsylvania
| | - Thomas M. Todoran
- Division of Cardiovascular Medicine, Department of Internal Medicine, Medical University of South Carolina, Charleston
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas
| | - Victor Tapson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Cedars-Sinai Hospital, Los Angeles, California
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Porres-Aguilar M, Jiménez D. Risk adapted management of acute pulmonary embolism in women. Thromb Res 2020; 181 Suppl 1:S29-S32. [PMID: 31477224 DOI: 10.1016/s0049-3848(19)30363-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/15/2019] [Accepted: 03/22/2019] [Indexed: 01/07/2023]
Abstract
Acute pulmonary embolism (PE) represents the third most common cause of cardiovascular death worldwide. Clinical practice guidelines recommend prompt risk stratification of patients with acute PE. Prognostication may accurately identify: 1) hemodynamically unstable (i.e., high-risk) patients with PE, who might benefit from recanalization therapies (i.e., thrombolysis, embolectomy); 2) intermediate- to high-risk patients with PE, who might require monitoring and recanalization procedures if early hemodynamic decompensation occurs; and 3) low-risk patients with PE, who might benefit from an abbreviated hospital stay or outpatient therapy. A fourth group of patients should not undergo escalated or home therapy (intermediate- to low-risk PE). Studies of patients with proven acute PE have shown conflicting data regarding the association between sex and presentation and short-term clinical course in patients with acute symptomatic PE. Therefore, at this time sex differences should not dictate different approaches to prognostication and management.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Medicine, Division of Hospital Medicine, Northcentral Baptist Medical Center, San Antonio, Texas, USA
| | - David Jiménez
- Respiratory Department and Medicine Department, Ramón y Cajal Hospital and Alcalá University, IRYCIS, Madrid, Spain.
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Rodríguez Adrada E, Espinosa B, Calvo Porqueras B. Consideraciones sobre el pronóstico de los pacientes con tromboembolia pulmonar. Med Clin (Barc) 2019; 153:130. [DOI: 10.1016/j.medcli.2018.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 11/28/2022]
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Quezada CA, Bikdeli B, Villén T, Barrios D, Mercedes E, León F, Chiluiza D, Barbero E, Yusen RD, Jimenez D. Accuracy and Interobserver Reliability of the Simplified Pulmonary Embolism Severity Index Versus the Hestia Criteria for Patients With Pulmonary Embolism. Acad Emerg Med 2019; 26:394-401. [PMID: 30155937 DOI: 10.1111/acem.13561] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/18/2018] [Accepted: 08/22/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The objective was to assess and compare the accuracy and interobserver reliability of the simplified Pulmonary Embolism Severity Index (sPESI) and the Hestia criteria for predicting short-term mortality in patients with pulmonary embolism (PE). METHODS This prospective cohort study evaluated consecutive eligible adults with PE diagnosed in the emergency department (ED) at a large, tertiary, academic medical center in the era January 1, 2015, to December 30, 2017. We assessed and compared sPESI and Hestia criteria prognostic accuracy for 30-day all-cause mortality after PE diagnosis and their interobserver reliability for classifying patients as low risk or high risk. Two clinician investigators scored both prediction tools during the ED evaluation. We used the kappa statistic to test for agreement. RESULTS The 488-patient cohort had a mean (±SD) age of 69.0 (±17.1) years and an approximately even sex distribution. The investigators classified one-quarter of patients as low risk using the sPESI and Hestia criteria (28% vs. 27%, respectively). During the 30-day follow-up, 31 of the 488 (6.4%) patients died. Patients classified as low risk according to the sPESI and the Hestia criteria had a similar 30-day mortality (sPESI 0.7% [1/135], 95% confidence interval [CI] = 0.0%-4.0%; Hestia 2.3% [3/132], 95% CI = 0.5%-6.5%). The two observers had good agreement (κ = 0.80) for the Hestia criteria and very good agreement (κ = 0.97) for the sPESI. CONCLUSION The sPESI and the Hestia criteria had similar risk classification determination and prognostic accuracy for 30-day mortality after PE. However, the succinct and more objective sPESI had higher interobserver reliability than the Hestia criteria.
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Affiliation(s)
- Carlos Andrés Quezada
- Respiratory Department Ramón y Cajal Hospital Universidad de Alcala IRYCIS MadridSpain
| | - Behnood Bikdeli
- Division of Cardiology Department of Medicine Columbia University Medical Center New York‐Presbyterian Hospital New York NY
- Center for Outcomes Research and Evaluation (CORE) Yale University School of Medicine New Haven CT
- Cardiovascular Research Foundation New York NY
| | - Tomás Villén
- Emergency Department Hospital La Paz MadridSpain
| | - Deisy Barrios
- Respiratory Department Ramón y Cajal Hospital Universidad de Alcala IRYCIS MadridSpain
| | - Edwin Mercedes
- Respiratory Department Ramón y Cajal Hospital Universidad de Alcala IRYCIS MadridSpain
| | - Francisco León
- Respiratory Department Ramón y Cajal Hospital Universidad de Alcala IRYCIS MadridSpain
| | - Diana Chiluiza
- Respiratory Department Ramón y Cajal Hospital Universidad de Alcala IRYCIS MadridSpain
| | - Esther Barbero
- Respiratory Department Ramón y Cajal Hospital Universidad de Alcala IRYCIS MadridSpain
| | - Roger D. Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Education Washington University School of Medicine St. Louis MO
| | - David Jimenez
- Respiratory Department Ramón y Cajal Hospital Universidad de Alcala IRYCIS MadridSpain
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