Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis

Abstract

Objective: To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes.

Design: Systematic review and meta-analysis.

Data sources: OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature.

Eligibility criteria: Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE.

Data extraction: Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers.

Data analysis: Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy.

Results: We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate).

Conclusions: We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.

Keywords: prediction rules; prognostic models; pulmonary embolism; risk stratification; systematic review.

Figure 1

Flow chart of search results.

Figure 2

sROC plots showing test accuracy of PESI≥III cut-off associated with 30-day all-cause death: all studies (A) and external validation studies (B). HSROC, hierarchical summary receiver operating characteristic; PESI, Pulmonary Embolism Severity Index; sROC, summary receiver operating characteristic.

Figure 3

sROC plots showing test accuracy of sPESI≥1 cut-off associated with 30-day all-cause death: all studies (A) and external validation studies (B). HSROC, hierarchical summary receiver operating characteristic; PESI, Pulmonary Embolism Severity Index; sROC, summary receiver operating characteristic.