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A Prediction Rule to Identify Low-Risk Patients With Pulmonary Embolism
Drahomir Aujesky, MD, MSc;
D. Scott Obrosky, MSc;
Roslyn A. Stone, PhD;
Thomas E. Auble, PhD;
Arnaud Perrier, MD;
Jacques Cornuz, MD, MPH;
Pierre-Marie Roy, MD, PhD;
Michael J. Fine, MD, MSc
Arch Intern Med. 2006;166:169-175.
Background A simple prognostic model could help identify patients with pulmonary embolism who are at low risk of death and are candidates for outpatient treatment.
Methods We randomly allocated 15 531 retrospectively identified inpatients who had a discharge diagnosis of pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our rule to predict 30-day mortality using classification tree analysis and patient data routinely available at initial examination as potential predictor variables. We used data from a European prospective study to externally validate the rule among 221 inpatients with pulmonary embolism. We determined mortality and nonfatal adverse medical outcomes across derivation and validation samples.
Results Our final model consisted of 10 patient factors (age  70 years; history of cancer, heart failure, chronic lung disease, chronic renal disease, and cerebrovascular disease; and clinical variables of pulse rate 110 beats/min, systolic blood pressure <100 mm Hg, altered mental status, and arterial oxygen saturation <90%). Patients with none of these factors were defined as low risk. The 30-day mortality rates for low-risk patients were 0.6%, 1.5%, and 0% in the derivation, internal validation, and external validation samples, respectively. The rates of nonfatal adverse medical outcomes were less than 1% among low-risk patients across all study samples.
Conclusions This simple prediction rule accurately identifies patients with pulmonary embolism who are at low risk of short-term mortality and other adverse medical outcomes. Prospective validation of this rule is important before its implementation as a decision aid for outpatient treatment.
Author Affiliations: Division of General Internal Medicine, Department of Medicine (Drs Aujesky and Fine), Department of Biostatistics, Graduate School of Public Health (Dr Stone), and Department of Emergency Medicine (Dr Auble), University of Pittsburgh, and VA Center for Health Equity Research and Promotion and VA Pittsburgh Healthcare System (Drs Stone and Fine and Mr Obrosky), Pittsburgh, Pa; Department of Internal Medicine, University Outpatient Clinic, and Clinical Epidemiology Center, University of Lausanne, Lausanne (Drs Aujesky and Cornuz), and Division of General Internal Medicine, Department of Internal Medicine, University of Geneva, Geneva (Dr Perrier), Switzerland; and Department of Emergency Medicine, University of Angers, Angers, France (Dr Roy).
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