Key result
PESI incorrectly labels ~14% of ED patients with PE who suffer early major events as low risk.
Why the study?
The ability of the Pulmonary Embolism Severity Index (PESI) to predict freedom from clinically adverse outcomes during typical hospitalization after PE was not known.
Does the Pulmonary Embolism Severity Index (PESI) accurately predict freedom from short-term clinical deterioration in Emergency Department patients with pulmonary embolism?
Observational (n=245)
Does the Pulmonary Embolism Severity Index (PESI) accurately predict freedom from short-term clinical deterioration in Emergency Department patients with pulmonary embolism?
Effect estimate: Sensitivity 86% (95% CI 75-93)
Absolute Event Rate: 8.3% vs 38.2%
The PESI misclassified 14% of patients who experienced short-term clinical deterioration as low risk, suggesting caution when using it to determine safe early discharge within the first 5 days of PE diagnosis.
Low-risk PESI does not reliably exclude in-hospital adverse events after PE; leaves open its utility for early discharge decisions.
The Pulmonary Embolism Severity Index (PESI) has been shown to predict 30 and 90 day mortality after PE. However, whether the PESI predicts patients who will be free of clinically adverse outcomes during a typical hospitalisation is not known. Retrospective analysis of Emergency Department patients with PE from May 2006 to April 2008. We compiled demographics, data to calculate the PESI and a composite outcome. Patients were considered to have a negative PESI if they were in category I or II (≤85 points). Patients were considered to have the composite outcome if, within five days of diagnosis, they: A) had recurrent PE; B) developed a new cardiac dysrhythmia; C) required advanced cardiac life support; D) required respiratory support; E) required vasopressors; F) received thrombolysis; G) had major bleeding; H) returned to the ED; I) died. We enrolled 245 patients with PE. Of these, 115 (47%) were male, 204 (83%) were white. The mean age was 57 ± 17 years. The PESI identified 109 (44%) as low risk and 136 (56%) as high risk. Sixty-one (26%) patients had the outcome, of whom nine (14%) were characterised as low risk by the PESI. Test characteristics were: sensitivity 86% (95% confidence interval [CI]: 75%-93%), specificity 55% (95% CI: 47%-62%), NPV 63% (95% CI: 55%-70%), PPV 40% (95% CI: 31%-49%), LR(+) 1.9 (95% CI: 1.57-2.30) and LR(-) 0.26 (95% CI: 0.14-0.48). Of the patients who had an adverse clinical event or required a hospital-based intervention within the first five days after PE diagnosis, 14% were categorised by the PESI as safe for discharge [corrected] .
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Hariharan et al. (2011) conducted an observational in Pulmonary Embolism (n=245). Pulmonary Embolism Severity Index (PESI) low risk category vs. PESI high risk category was evaluated on Composite of recurrent PE, new cardiac dysrhythmia, ACLS, respiratory support, vasopressors, thrombolysis, major bleeding, return to ED, or death within 5 days (Sensitivity 86%, 95% CI 75-93). Among ED patients with pulmonary embolism, 14% of those who experienced an adverse clinical event within 5 days were incorrectly categorized as low risk by the PESI (sensitivity 86%; 95% CI 75-93%).
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