Key result
CPES fails as a standalone mortality predictor but modestly enhances PESI and ESC risk classification.
Why the study?
PESI and ESC risk classifications are widely used for early risk stratification of acute PE, and the CPES score was proposed to better identify normotensive shock, but their comparative prognostic performance needed evaluation.
Does the addition of the Composite PE Shock (CPES) score to PESI and ESC risk classification improve prognostic accuracy for 30-day mortality and need for advanced reperfusion therapy in adults with acute pulmonary embolism?
Cohort (n=404)
Yes
Does the addition of the Composite PE Shock (CPES) score to PESI and ESC risk classification improve prognostic accuracy for 30-day mortality and need for advanced reperfusion therapy in adults with acute pulmonary embolism?
Effect estimate: AUROC 0.420 for CPES alone; AUROC 0.722 for full model
The CPES score performs poorly as a standalone predictor of 30-day mortality in acute pulmonary embolism but provides modest incremental prognostic value when added to PESI and ESC risk classifications, particularly for predicting the need for advanced reperfusion therapy.
CPES may aid normotensive shock detection in PE; leaves open whether it outperforms PESI or ESC in prospective cohorts.
PESI and ESC risk classification are widely used for early risk stratification of acute pulmonary embolism (PE). The Composite PE Shock (CPES) score has been proposed to better identify normotensive shock. We compared the prognostic performance of PESI, ESC risk class, and CPES. We performed a retrospective chart review of consecutive adults with acute PE managed by PERT (PE Response Team) at three teaching hospitals within the Mount Sinai Health System from January 2020 through June 2024. Multivariable logistic regression was used to predict 30-day mortality. Discrimination was assessed using area under the receiver operating characteristic (AUROC) curves. Net Reclassification Improvement (NRI) and Integrated Discrimination Improvement (IDI) were calculated to assess incremental utility of CPES over PESI and ESC risk class. A total of 404 patients were included (median age: 65 years; 223 [55.2%] women). Median PESI and CPES scores were 82 (IQR: 66–104) and 3 (IQR: 2–4). ESC risk stratification was as follows: low: 12 (3.0%), intermediate low: 71 (17.6%), intermediate high: 235 (58.2%), and high-risk: 86 (21.3%). AUROC for predicting 30-day mortality of PESI, ESC risk class, and CPES were 0.706, 0.643, and 0.420 respectively, and for a two-index model (PESI + ESC), and the full model (PESI + ESC + CPES) were 0.650, and 0.722, respectively. Relative to the two-index model, the full model increased specificity by 10% and decreased sensitivity by 3.7% (NRI: 6.3%, IDI: 1.3%), consistent with modest incremental reclassification. The strongest incremental signal for CPES was observed for receipt of advanced reperfusion therapy, where addition of CPES to PESI and ESC increased AUROC from 0.664 to 0.775. In a contemporary PERT cohort of patients with acute PE, CPES performed poorly as a standalone predictor of 30-day mortality but provided modest conditional incremental information when added to PESI and ESC risk classification. CPES showed a stronger association with receipt of advanced reperfusion therapy, suggesting that it may capture shock physiology relevant to escalation decisions.
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Wang et al. (2026) conducted a cohort in Acute pulmonary embolism (n=404). Composite PE Shock (CPES) score vs. PESI and ESC risk classification was evaluated on 30-day all-cause mortality (AUROC 0.420 for CPES alone; AUROC 0.722 for full model). The Composite PE Shock (CPES) score performed poorly as a standalone predictor of 30-day mortality (AUROC 0.420) but provided modest incremental value when added to PESI and ESC risk classification (AUROC 0.722).
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