Pulmonary embolism (PE) generally occurs when a blood clot that develops in the veins of the leg or pelvis becomes dislodged and results in sudden blockage of an artery in the lung. It is a major health problem in the United States, causing more than 100,000 hospitalizations in 2002, according to background information in the article. The condition can be fatal, but evidence suggests that nonmassive PE, which is not accompanied by respiratory failure or other serious complications, could effectively and safely be treated on an outpatient basis, the authors write.
Previous studies have shown that outpatient treatment for PE also could be economically beneficial--the authors estimate that if 20 percent of people with PE were treated as outpatients, up to $91 million per year could be saved in the United States alone. However, "outpatient treatment for nonmassive PE is not widely accepted because no explicit clinical criteria exist to accurately identify patients with PE who are at low risk of adverse outcomes," they write. "Therefore, we sought to develop an objective and easily applied clinical prediction rule to identify patients with PE at low risk of short-term mortality and other adverse medical outcomes who are candidates for outpatient treatment."
Drahomir Aujesky, M.D., M.Sc., University of Lausanne, Switzerland, and colleagues developed this prediction rule or model by evaluating 15,531 admitted patients who received a discharge diagnosis of PE from 186 Pennsylvania hospitals. By concentrating on 10,354 patients, they identified 10 risk factors that indicated a greater risk of short-term death (within 30 days), including an age of 70 years or older; a history of cancer, heart failure, chronic lung disease or chronic kidney disease; cardiovascular disease; altered mental status; a high pulse rate; low systolic blood pressure; and reduced oxygen saturation in arterial blood. Patients without any of these factors are considered low-risk and eligible for outpatient treatment.
The researchers then tested their model on the remaining 5,177 participants in the original study group and by using data from a previous study of 221 Swiss patients with PE. Low numbers of patients in these two groups--1.5 percent and none, respectively--who were low-risk according to the model died within 30 days, and less than 1 percent developed non-fatal complications. "This simple prediction rule accurately identifies patients with pulmonary embolism who are at low risk of short-term mortality and other adverse medical outcomes," the authors write. "Prospective validation of this rule is important before its implementation as a decision aid for outpatient treatment."
(Arch Intern Med. 2006; 166: 169-175. Available pre-embargo to media at www.jamamedia.org.)
Editor's Note: This study was funded by a grant from the National Heart, Lung, and Blood Institute, Bethesda, Md.; by the Swiss Foundation in Medicine and Biology, Bern, and the Swiss Medical Association, Bern; and by a Career Development Award from the National Institute of Allergy and Infectious Diseases, Bethesda.
Editorial: Important to Identify Patients at Higher Risk
Although previous studies have linked certain indicators with prognosis for patients with PE, none have been used to group patients by risk, writes Lisa K. Moores, M.D., Walter Reed Army Medical Center, Washington, D.C., in an accompanying editorial. "The important question may not be who has PE but who is likely to have a recurrent fatal PE?" she writes.
"The study by Aujesky and colleagues is exciting because it is the first to combine several factors into a score that can be used to determine the appropriate treatment setting," Dr. Moores writes. "Perhaps more importantly, the risk score can be calculated quickly and reliably with clinical data easily obtained in the initial history review and physical examination."
(Arch Intern Med. 2006; 166: 147-148. Available pre-embargo to the media at www.jamamedia.org.)
To contact editorialist Lisa K. Moores, M.D., e-mail firstname.lastname@example.org.
Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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