Prognostic Accuracy of Clinical Prediction Rules for Early Post-Pulmonary Embolism All-Cause Mortality: A Bivariate Meta-Analysis.
Chest. 2014 Oct 9;
Authors: Kohn CG, Mearns EL, Parker MW, Hernandez AV, Coleman CI
Abstract
Abstract: Background:Studies suggest outpatient treatment or early discharge of acute pulmonary embolism (aPE) is reasonable for those deemed to be at low-risk of early mortality. We sought to determine clinical prediction rule (CPR) accuracy for identifying aPE patients at low-risk for mortality. Methods:We performed a literature search of Medline and Embase from January 2000-March 2014, along with a manual search of references. We included studies deriving/validating a CPR for early post-aPE all-cause mortality and providing mortality data over at least the index aPE hospitalization but ≤90-days. A bivariate model was used to pool sensitivity and specificity estimates using a random-effects approach. Traditional random-effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low-risk for early mortality and their odds ratios for death compared to high-risk patients. Results:Forty studies (52 cohort-CPR analyses) reporting on 11 CPRs were included. The highest sensitivities were observed with the Global Registry of Acute Coronary Events (GRACE)(0.99, 95%CI=0.89-1.00), Aujesky 2006 (0.97, 95%CI=0.95-0.99), simplified Pulmonary Embolism Severity Index (sPESI)(0.92, 95%CI=0.89-0.94), PESI (0.89, 95%CI=0.87-0.90) and European Society of Cardiology (ESC)(0.88, 95%CI=0.77-0.94) tools; with remaining CPR sensitivities ranging from 0.41-0.82. Of these 5 CPRs with the highest sensitivities, none had a specificity >0.48. They suggested anywhere from 22%-45% of aPE patients were at low-risk; and that low-risk patients had a 77%-97% lower odds of death compared to those at high-risk. Conclusions:Numerous CPRs for prognosticating early mortality in aPE patients are available, but not all demonstrate the high sensitivity needed to reassure clinicians.
Background: Studies suggest outpatient treatment or early discharge of acute pulmonary embolism (aPE) is reasonable for those deemed to be at low-risk of early mortality. We sought to determine clinical prediction rule (CPR) accuracy for identifying aPE patients at low-risk for mortality.
Methods: We performed a literature search of Medline and Embase from January 2000-March 2014, along with a manual search of references. We included studies deriving/validating a CPR for early post-aPE all-cause mortality and providing mortality data over at least the index aPE hospitalization but ≤90-days. A bivariate model was used to pool sensitivity and specificity estimates using a random-effects approach. Traditional random-effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low-risk for early mortality and their odds ratios for death compared to high-risk patients.
Results: Forty studies (52 cohort-CPR analyses) reporting on 11 CPRs were included. The highest sensitivities were observed with the Global Registry of Acute Coronary Events (GRACE)(0.99, 95%CI=0.89-1.00), Aujesky 2006 (0.97, 95%CI=0.95-0.99), simplified Pulmonary Embolism Severity Index (sPESI)(0.92, 95%CI=0.89-0.94), PESI (0.89, 95%CI=0.87-0.90) and European Society of Cardiology (ESC)(0.88, 95%CI=0.77-0.94) tools; with remaining CPR sensitivities ranging from 0.41-0.82. Of these 5 CPRs with the highest sensitivities, none had a specificity >0.48. They suggested anywhere from 22%-45% of aPE patients were at low-risk; and that low-risk patients had a 77%-97% lower odds of death compared to those at high-risk.
Conclusions: Numerous CPRs for prognosticating early mortality in aPE patients are available, but not all demonstrate the high sensitivity needed to reassure clinicians.
PMID: 25317677 [PubMed - as supplied by publisher]