What is the clinical evidence from this study?

Study design: Cohort. Population: Acute symptomatic pulmonary embolism (n=18707). Intervention: RIETE score vs. PESI and sPESI. Primary outcome: All-cause mortality, recurrent PE, and major bleeding up to 10 days after PE diagnosis (AUC 0.77, 95% CI 0.75-0.78, p=<0.05).

June 26, 2015

Identification of Low-Risk Patients with Acute Symptomatic Pulmonary Embolism for Outpatient Therapy

Q: What are the key findings of this study?

The RIETE score outperformed PESI and sPESI in predicting short-term complications in acute symptomatic PE, achieving an AUC of 0.77 (95% CI, 0.75-0.78) compared to 0.72 for PESI (P<0.05).

Key Result

The RIETE score outperformed PESI and sPESI in predicting short-term complications in acute symptomatic PE, achieving an AUC of 0.77 (95% CI, 0.75-0.78) compared to 0.72 for PESI (P<0.05).

Study Design

Type

Cohort (n=18,707)

Multicenter

Yes

Structured PICO

Does the RIETE score improve the identification of low-risk patients with acute symptomatic pulmonary embolism compared to PESI and sPESI?

Population

18,707 patients with acute symptomatic pulmonary embolism prospectively enrolled in the international RIETE registry

Intervention

RIETE score (clinical prediction rule including chronic heart failure, recent immobilization, recent major bleeding, cancer, hypotension, tachycardia, hypoxemia, renal insufficiency, and abnormal platelet count)

Comparator

Pulmonary Embolism Severity Index (PESI) and Simplified PESI (sPESI)

Outcome

Composite of all-cause mortality, recurrent PE, and major bleeding up to 10 days after PE diagnosiscomposite

The newly developed RIETE score outperforms PESI and sPESI in identifying patients with acute symptomatic PE at low risk for short-term complications, potentially aiding in outpatient triage.

Main Result

Effect estimate: AUC 0.77 (95% CI 0.75-0.78)

Absolute Event Rate: 0.77% vs 0.72%

p-value: p=<0.05

Abstract

Abstract Rationale Patients with acute symptomatic pulmonary embolism (PE) deemed to be at low risk for early complications might be candidates for partial or complete outpatient treatment. Objectives To develop and validate a clinical prediction rule that accurately identifies patients with PE and low risk of short-term complications and to compare its prognostic ability with two previously validated models (i.e., the Pulmonary Embolism Severity Index PESI and the Simplified PESI sPESI) Methods Multivariable logistic regression of a large international cohort of patients with PE prospectively enrolled in the RIETE (Registro Informatizado de la Enfermedad TromboEmbólica) registry. Measurements and Main Results All-cause mortality, recurrent PE, and major bleeding up to 10 days after PE diagnosis were determined. Of 18,707 eligible patients with acute symptomatic PE, 46 (0.25%) developed recurrent PE, 203 (1.09%) bled, and 471 (2.51%) died. Predictors included in the final model were chronic heart failure, recent immobilization, recent major bleeding, cancer, hypotension, tachycardia, hypoxemia, renal insufficiency, and abnormal platelet count. The area under receiver-operating characteristic curve was 0.77 (95% confidence interval CI, 0.75–0.78) for the RIETE score, 0.72 (95% CI, 0.70–0.73) for PESI (P 0.05), and 0.71 (95% CI, 0.69–0.73) for sPESI (P 0.05). Our RIETE score outperformed the prognostic value of PESI in terms of net reclassification improvement (P 0.001), integrated discrimination improvement (P 0.001), and sPESI (net reclassification improvement, P 0.001; integrated discrimination improvement, P 0.001). Conclusions We built a new score, based on widely available variables, that can be used to identify patients with PE at low risk of short-term complications, assisting in triage and potentially shortening duration of hospital stay.

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