Predicting Deterioration in Patients With Normotensive Acute Pulmonary Embolism Using Clinical-Imaging Features: A Multicenter Prospective Cohort Study

Abstract

Background: Prioritization of management strategies in patients with normotensive acute pulmonary embolism is based on the identification of individuals at risk for early deterioration. This study aims to develop and validate a novel score for deterioration prediction using clinical-imaging features.

Methods: This is multicenter, prospective observational cohort study (AOAPECT [Adverse Outcomes in Acute Pulmonary Embolism patients using Computed Tomography pulmonary angiography] cohort, NCT05098769). Registered-enrolled patients with normotensive acute pulmonary embolism were collected consecutively from 5 centers across China. Derivation set was established from 2 centers, while local and nonlocal external validation sets were derived from the remaining 3 centers. The end point was pulmonary embolism-related deterioration within 30 days after admission. Deterioration-related candidate predictors consisted of clinical, laboratory and computed tomography pulmonary angiography parameters were screened and then split into dichotomous values. The predictive score was conducted by a multivariable logistics regression and validated. Score performances were quantified using the area under the receiver operating characteristic curve.

Results: Of 3310 enrolled patients including 1 derivation (n=2061) and 2 validation sets (n=969 and 280), 272 patients (8.2%) experienced deterioration. In the derivation set, an increased risk of deterioration was observed with right to left ventricle diameter ratio ≥1.2, appearance of pulmonary vein sign on computed tomography pulmonary angiography, and heart rate ≥110 beats/min. When at least 2 out of 3 items were positive, patients were assigned to the high-risk deterioration group. This PE-RPH score revealed good discrimination to deterioration in derivation and validation sets (area under the receiver operating characteristic curve, 0.82, 0.82, and 0.80).

Conclusions: This PE-RPH score incorporating 2 computed tomography pulmonary angiography parameters and heart rate may help predict the deterioration risk in patients with normotensive acute pulmonary embolism. REGISTRATION: https://clinicaltrials.gov; identifier: NCT05098769.

Keywords: clinical deterioration; heart rate; heart ventricles; pulmonary embolism; pulmonary vein.

Figure 1. CTPA parameter measurement and RV/LV diameter ratio and PV sign illustration.

A, RV and LV diameter measurements in 4‐chamber view: the related ratio of RV to LV ratio <1.2; B, RV and LV diameter measurements in 4‐chamber view: the related ratio of RV to LV ratio >1.2; C, PV sign in the confluence of right PV with LA. Observation of any main PV without a contrast agent was defined as a PV sign. At the right lung, PAs were blocked completely, and an accompanying PV sign was observed. In contrast, the left lung showed partial blockage in the PAs, and no PV sign was observed. D, PV sign in the confluence of left PV with LA. At the left lung, PAs were blocked completely, and an accompanying PV sign was observed. In contrast, the right lung showed partial blockage in the PAs, and no PV sign was observed. CTPA indicates computed tomography pulmonary angiography; LA, left atrium; LV, left ventricle; PA, pulmonary artery; PV, pulmonary vein; RV, right ventricle and LV, left ventricle.

Figure 2. The overview of model development, validation, and performance.

A, The study design and overview of model development and validation; B, PE‐RPH score and its deterioration risk stratification; C, The performance and comparison of discriminatory power to deterioration. AUC indicates area under the receiver operating characteristic curve; CTPA, computed tomography pulmonary angiography; ESC, European Society of Cardiology; HR, heart rate; LV, left ventricle; PE‐RPH, pulmonary embolism‐right‐to‐left ventricle diameter ratio, pulmonary vein sign, heart rate; PV, pulmonary vein; RV, right ventricle; and sPESI, simplified Pulmonary Embolism Severity Index.