Systematic screening of risk factors in acute venous thrromboembolism population revealed the utility of PESI score as a predictor of 3-year prognosis -insights from COMMAND VTE registry

Background The pulmonary embolism severity index (PESI) score is an established risk score for the 30-day prognosis of the acute phase of pulmonary embolism (PE).(1) We recently reported temporal changes in long-term outcomes of venous thromboembolism (VTE) from the warfarin era to the direct oral anticoagulant era in a total of 8224 patients in Japan.(2) In this population, we aimed to find a novel predictor of death by using a machine-learning approach. Methods All the participants registered in COMMAND-VTE registries 1 and 2 were included. A single imputation method was applied for missing values, and LASSO regression was used for systematic screening for mortality risks. After the screening, suggested risk factors and historical factors were examined in conventional Cox regression. Results Among 78 factors at baseline, LASSO regression selected 9 significant predictors that either positively or negatively affected death (figure 1 left). The most important factor was active malignancy. Even though the mean follow-up term was 948, the simplified PESI score was a significant predictor of death. Multivariable analysis confirmed that active malignancy is the most important predictor of death (HR 6.44, 95%CI 5.78-7.17) and also PESI score was a significant predictor (HR 1.13, 95%CI 1.09-1.18, figure 1 right). The Kaplan-Meir curve showed that the PESI score stratifies the mortality risk according to the score and the prognosis of the deep vein thrombosis (DVT) alone was equivalent to that of the pulmonary embolism population with PESI score 1 (figure 2). Discussions and Conclusions: In this large VTE registry, active malignancy has the strongest impact on death. Other conventional risk factors including age have a lower hazard ratio compared to active malignancy. The systematic screening revealed that the PESI score is the significant predictor of death in 2.6-year follow-up. As previously reported from the COMMAND VTE 1 population, the PESI score was useful for predicting prognosis within 30 days.(3) Our current results suggested that the PESI score is also useful in predicting the long-term prognosis of the PE population. Among VTE patients, DVT alone is not necessarily the lowest risk compared to the PE population stratified by PESI score. The prognosis of DVT alone was the same as that of PE with a PESI score of 1.