Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model

The European Society of Cardiology (ESC) has proposed an updated risk stratification model for death in patients with acute pulmonary embolism based on clinical scores (Pulmonary Embolism Severity Index (PESI) or simplified PESI (sPESI)), right ventricle dysfunction (RVD) and elevated serum troponin (2014 ESC model). We assessed the ability of the 2014 ESC model to predict 30-day death after acute pulmonary embolism. Consecutive patients with symptomatic, confirmed pulmonary embolism included in prospective cohorts were merged in a collaborative database. Patients' risk was classified as high (shock or hypotension), intermediate-high (RVD and elevated troponin), intermediate-low (RVD or increased troponin or none) and low (sPESI 0). Study outcomes were death and pulmonary embolism-related death at 30 days. Among 906 patients (mean +/- SD age 68 +/- 16, 489 females), death and pulmonary embolism-related death occurred in 7.2% and 4.1%, respectively. Death rate was 22% in high-risk (95% CI 14.0-29.8), 7.7% in intermediate-high-risk (95% CI 4.5-10.9) and 6.0% in intermediate-low-risk patients (95% CI 3.4-8.6). One of the 196 low-risk patients died (0.5%, 95% CI 0-1.0; negative predictive value 99.5%). By using the 2014 ESC model, RVD or troponin tests would be avoided in about 20% of patients (sPESI 0), preserving a high negative predictive value. Risk stratification in patients at intermediate risk requires further improvement.