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Vol. 43. Issue 11.
Pages 617-622 (January 2007)
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Vol. 43. Issue 11.
Pages 617-622 (January 2007)
Original Articles
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A Clinical Prediction Rule for Identifying Short-Term Risk of Adverse Events in Patients With Pulmonary Thromboembolism
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Fernando Uresandia,
Corresponding author
fern2148@separ.es

Correspondence: Dr. F. Uresandi. Servicio de Neumología. Hospital de Cruces. Barrio Labeaga, s/n. 48903 Barakaldo. Bizkaia. España
, Remedios Oterob, Aurelio Cayuelac, Miguel Ángel Cabezudod, David Jiméneze, Elena Lasernaf, Francisco Congetg, Miquel Oribeh, Dolores Nauffali
a Servicio de Neumología, Hospital de Cruces, Barakaldo, Bizkaia, Spain
b Servicio de Neumología, Hospital Virgen del Rocío, Sevilla, Spain
c Unidad de Apoyo a la Investigación, Hospital Virgen del Rocío, Sevilla, Spain
d Servicio de Neumología, Hospital Central de Asturias, Oviedo, Asturias, Spain
e Servicio de Neumología, Hospital Ramón y Cajal, Madrid, Spain
f Sección de Neumología, Servicio de Medicina Interna, Hospital San Juan de Dios, Bormujos, Sevilla, Spain
g Servicio de Neumología, Hospital Clínico Lozano Blesa, Zaragoza, Spain
h Servicio de Neumología, Hospital de Galdakao, Galdakao, Bizkaia, Spain
i Servicio de Neumología, Hospital La Fe, Valencia, Spain
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Objetive

To identify patients with a low short-term risk of complications following acute pulmonary thromboembolism.

Patients and methods

A prospective multicenter study was conducted in 8 Spanish hospitals; 681 consecutive outpatients diagnosed with pulmonary thromboembolism were enrolled. Clinically significant variables were weighted using coefficients derived from a logistic regression model in order to optimize the diagnostic performance of a clinical prediction rule to predict the following complications within 10 days of acute pulmonary thromboembolism: death, recurrent thromboembolism, and major or minor bleeding.

Results

Forty-three patients (6.3%) had 51 complications. These included 33 deaths, 12 major bleeding episodes, and 6 minor bleeding episodes. The clinical variables used in the prediction rule were assigned the following scores: recent major bleeding episode and cancer with metastasis, 4 points each; creatinine levels of over 2 mg/dL, 3 points; cancer without metastasis and immobility due to a recent medical condition, 2 points each; and absence of surgery in the past 2 months and an age of over 60 years, 1 point each. A risk score of 2 or less, obtained by 47.8% of patients, indicated a low short-term risk of developing complications following pulmonary thromboembolism. The area under the receiver operating characteristic curve for the prediction rule was 0.75 (95% confidence interval [CI], 0.67–0.83). For this cutoff point, sensitivity was 82.9% (95% CI, 68.7–91.5) and the likelihood ratios for a positive and negative test result were 1.63 (95% CI, 1.39–1.92), and 0.35 (95% CI, 0.18–0.69), respectively.

Conclusions

Our clinical prediction rule could be useful for identifying patients with a low risk of complications in the 10 days following acute pulmonary thromboembolism. Those patients would be eligible for consideration for outpatient treatment.

Key words:
Pulmonary thromboembolism
Clinical prediction rule
Short-term complications
Objetivo

Identificar a pacientes con riesgo bajo de complicaciones a corto plazo tras un episodio agudo de tromboembolia pulmonar (TEP).

Pacientes y métodos

Se trata de un estudio multicéntrico y prospectivo, realizado en 8 hospitales españoles, en el que se incluyó a un total de 681 pacientes ambulatorios consecutivos con diagnóstico de TEP. Las variables con significación clínica se ponderaron a partir de los coeficientes del modelo logístico, con el objetivo de maximizar las características diagnósticas de la escala clínica de predicción de eventos a corto plazo: muertes, recidivas tromboembólicas o complicaciones hemorrágicas graves y no graves en los 10 primeros días.

Resultados

Hubo 51 complicaciones en 43 pacientes (6,3%): un total de 33 fallecimientos, 12 hemorragias graves y 6 no graves. La puntuación clínica asignada a las variables de la escala de predicción fue la siguiente: hemorragia grave reciente y cáncer con metástasis, 4 puntos cada una; valores de creatinina mayores de 2 mg/dl, 3 puntos; cáncer sin metástasis e inmovilización por enfermedad médica reciente, 2 puntos cada una, y ausencia de cirugía en los últimos 2 meses y edad superior a 60 años, 1 punto cada una. Una puntuación de 2 o menor, que obtuvo el 47,8% de nuestros pacientes, indica un riesgo bajo de presentar complicaciones a corto plazo tras la TEP. El área bajo la curva de eficacia diagnóstica de la escala es de 0,75 (intervalo de confianza [IC] del 95%, 0,67–0,83). Para ese punto de corte la sensibilidad es del 82,9% (IC del 95%, 68,7–91,5), el cociente de probabilidad positiva del 1,63 (IC del 95%, 1,39–1,92) y el cociente de probabilidad negativa de 0,35 (IC del 95%, 0,18–0,69).

Conclusiones

Nuestra escala clínica de puntuación podría ser útil para identificar a pacientes con riesgo bajo de presentar complicaciones durante los 10 primeros días tras un episodio de TEP aguda. Estos pacientes serían los candidatos sobre los que plantear un estudio que avale el tratamiento domiciliario de la TEP.

Palabras clave:
Tromboembolia pulmonar
Escala clínica de predicción
Complicaciones a corto plazo
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References
[1]
PD Stein, ML Terrin, CA Hales, HI Palevsky, AH Satzman, T Thompson, et al.
Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease.
Chest, 100 (1991), pp. 598-603
[2]
RH White.
The epidemiology of venous thromboembolism.
Circulation, 107 (2003), pp. 4-8
[3]
HR Büller, G Agnelli, RD Hull, TM Hyers, MH Prins, GE Raskob.
Antithrombotic therapy for venous thromboembolic disease. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest, 126 (2004), pp. 410-428
[4]
M Levine, M Gent, J Hirsh, J Leclerc, D Anderson, J Wietz, et al.
A comparison of low-molecular-weight heparin administered primarily at home with unfractioned heparin administered in the hospital for proximal deep-vein thrombosis.
N Engl J Med, 334 (1996), pp. 677-681
[5]
M Koopman, P Prandoni, F Piovella, P Ockelford, D Brandjes, J van der Meer, et al.
Treatment of venous thrombosis with intravenous unfractioned heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home.
N Engl J Med, 334 (1996), pp. 682-687
[6]
P Wells, M Kovacs, J Bormanis, M Forgie, D Goudie, B Morrow, et al.
Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin.
Arch Intern Med, 158 (1998), pp. 1809-1812
[7]
M Kovacs, D Anderson, B Morrow, L Gray, D Touchie, P Wells.
Outpatient treatment of pulmonary embolism with dalteparin.
Thromb Haemost, 83 (2000), pp. 209-211
[8]
AY Lim, DG Parr, DE Stableforth, M Fellows, R Fontaine, CI Fegan.
Early discharge and home supervision of patients with pulmonary embolism treated with low-molecular-weight heparin.
Eur J Intern Med, 14 (2003), pp. 89-93
[9]
J Douketis, C Kearon, S Bates, E Duku, J Ginsberg.
Risk of fatal pulmonary embolism in patients with treated venous thromboembolism.
JAMA, 279 (1998), pp. 458-462
[10]
J Douketis, G Foster, M Crowther, M Prins, J Ginsberg.
Clinical risk factors and timing of recurrent venous thromboembolism during the initial 3 months of anticoagulant therapy.
Arch Intern Med, 160 (2000), pp. 3431-3436
[11]
PS Wells, MA Forgie, M Simms, A Greene, D Touchie, G Lewis, et al.
The outpatient bleeding rates in patients treated for deep venous thrombosis and pulmonary embolism.
Arch Intern Med, 163 (2003), pp. 917-920
[12]
J Wicki, A Perrier, TV Perneger, H Bounameaux, AF Junod.
Predicting adverse outcome in patients with acute pulmonary embolism: a risk score.
Thromb Haemost, 84 (2000), pp. 548-552
[13]
MR Nendaz, P Bandelier, D Aujesky, J Cornuz, PM Roy, H Bounameaux, et al.
Validation of a risk score identifying patients with acute pulmonary embolism, who are at low risk of clinical adverse outcome.
Thromb Haemost, 91 (2004), pp. 1232-1236
[14]
D Aujesky, DS Obrosky, RA Stone, TE Auble, A Perrier, J Cornuz, et al.
Derivation and validation of a prognostic model for pulmonary embolism.
Am J Respir Crit Care Med, 172 (2005), pp. 1041-1046
[15]
D Aujesky, PM Roy, CP Le Manach, F Verschuren, G Meyer, DS Obrosky, et al.
Validation of a model to predict adverse outcomes in patients with pulmonary embolism.
Eur Heart J, 27 (2006), pp. 476-481
[16]
The PIOPED Investigators.
Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).
JAMA, 263 (1990), pp. 2753-2759
[17]
L la Vecchia, F Ottani, L Favero, GL Spadaro, A Rubboli, C Boanno, et al.
Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism.
Heart, 90 (2004), pp. 633-637
[18]
M ten Wolde, M Söhne, E Quak, MR MacGillavry, HR Büller.
Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism.
Arch Intern Med, 164 (2004), pp. 1685-1689

This study was funded by grants from the Instituto de Salud Carlos III of the Spanish Ministry of Health and Consumer Affairs (2003-2006) and from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) (2005).

Copyright © 2007. Sociedad Española de Neumología y Cirugía Torácica (SEPAR)
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