Cardiovascular Risk Assessment of Pulmonary Embolism With the GRACE Risk Score

doi:10.1016/j.amjcard.2012.10.020

The American Journal of Cardiology

Volume 111, Issue 3, 1 February 2013, Pages 425-431

https://doi.org/10.1016/j.amjcard.2012.10.020 Get rights and content

Despite the existence of several risk scores, the accurate prediction of the prognosis in pulmonary embolism (PE) remains a challenge. The Global Registry of Acute Coronary Events (GRACE) risk score has a high diagnostic performance for adverse outcomes in acute coronary syndrome. We aimed to assess the applicability and extend the use of the GRACE risk score to PE. A case-control study of 206 consecutive patients admitted with PE was performed. The GRACE, Geneva, Simplified Pulmonary Embolism Severity Index, Shock Index, and European Society of Cardiology risk scores were tested for the prediction of the primary end point: all-cause 30-day mortality. Comparisons between GRACE and the other risk scores were performed using receiver operating characteristic area under the curve and the integrated discrimination improvement index. All-cause 30-day mortality was observed in 18.9% of the patients. Unlike the other classifications, no adverse outcomes were observed in patients classified as low risk using the GRACE risk score (100% negative predictive value for GRACE risk score ≤113). The GRACE score showed greater discriminative performance than the Geneva score (area under the curve 0.623, 95% confidence interval [CI] 0.53 to 0.71), Shock Index (area under the curve 0.639, 95% CI 0.55 to 0.73), European Society of Cardiology (area under the curve 0.662, 95% CI 0.57 to 0.76), and Simplified Pulmonary Embolism Severity Index (area under the curve 0.705, 95% CI 0.61 to 0.80), although statistical significance was not reached. The integrated discrimination improvement index suggested a more appropriate risk classification with the GRACE score. In conclusion, our results have demonstrated that the GRACE risk score can accurately predict 30-day mortality in patients admitted for acute PE. Compared to previously proposed PE prediction rules, the GRACE risk score presented improved overall risk classification.

Section snippets

Methods

We performed a case-control study of 206 consecutive patients (mean age 70.3 ± 15.6 years, 41.3% men) with an “International Diseases Classification, 10th revision,” discharge code of PE from January 2007 to December 2010. A clinical review of each case was performed to ensure that the “International Diseases Classification, 10th revision,” coding referred to acute PE. Baseline data were collected at the PE diagnosis, and the prognostic scores (Geneva prognostic score, sPESI, ESC, Shock Index,

Results

The patients' baseline clinical and analytical and imaging characteristics are listed in Table 1. In our population sample, 39 patients (18.9%) died within 30 days of presentation, with 33 corresponding to in-hospital mortality. No patient was lost to follow-up.

Hemodynamic shock was documented in 15 patients (7.3%), and no cases of cardiac arrest at admission were reported. Regarding specific medical interventions, thrombolysis was used in 19 patients (9.2%), mechanical ventilation in 7 (3.4%),

Discussion

Acute PE is a cardiovascular emergency with a wide prognostic variability. Mortality rates have differed greatly among studies, ranging from 1.1% to 22%.13, 14, 15, 16 The lower mortality rates seen in the recent PE registries15, 16 were thought to be because of younger and less ill cohort populations and possibly, as mentioned by the Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry (EMPEROR) investigators,¹⁶ to a not truly random or representative sample.

Disclosures

The authors have no conflicts of interest to disclose.

References (20)

M. Righini et al.
The Simplified Pulmonary Embolism Severity Index (SPESI): validation of a clinical prognostic model for pulmonary embolism
J Thromb Haemost
(2011)
P. Berdagué et al.
Use of N-terminal prohormone brain natriuretic peptide assay for etiologic diagnosis of acute dyspnea in elderly patients
Am Heart J
(2006)
W. Kasper et al.
Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry
J Am Coll Cardiol
(1997)
S.Z. Goldhaber et al.
Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)
Lancet
(1999)
C.V. Pollack et al.
Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry)
J Am Coll Cardiol
(2011)
S. Vanni et al.
Comparison of two prognostic models for acute pulmonary embolism: clinical vs. right ventricular dysfunction-guided approach
J Thromb Haemost
(2011)
A. Torbicki et al.
Guidelines on the diagnosis an management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)
Eur Heart J
(2008)
J. Wicki et al.
Predicting adverse outcome in patients with acute pulmonary embolism: a risk score
Thromb Haemost
(2000)
D. Jiménez et al.
Simplification of the Pulmonary Embolism Severity Index for prognostication in patients with acute symptomatic pulmonary embolism
Arch Intern Med
(2010)
R. Otero et al.
Haemodynamically unstable pulmonary embolism in the RIETE registry: systolic blood pressure or shock index
Eur Respir J
(2007)

There are more references available in the full text version of this article.

Cited by (21)

Intermediate-high risk pulmonary embolism: When teamwork really matters
2024, Thrombosis Update
Pulmonary embolism is a common disease associated with significant morbidity and mortality. Existing validated risk stratification tools have enabled the rapid identification of patients with low versus high-risk pulmonary embolism. Intermediate-high risk pulmonary embolism is defined as pulmonary embolism with haemodynamic stability, evidence of right ventricular dysfunction and elevated cardiac biomarkers. The therapeutic management of intermediate-high risk pulmonary embolism in the acute setting is challenging as these patients are often unwell, but do not fulfil criteria for high-risk pulmonary embolism. Although current guidelines recommend prompt first-line treatment with systemic anticoagulation and monitoring for deterioration, alternative strategies are being increasingly considered in this cohort. These include systemic or catheter-directed thrombolysis, surgical embolectomy, and mechanical circulatory support. In this case series, we discuss three cases of intermediate-high risk pulmonary embolism with a focus on multidisciplinary decision making in clinical management. Following on from this, we provide a brief narrative review of the current literature and guidelines surrounding this topic, considering the risks and benefits of alternative therapy options on patient outcomes.
Can GRACE Risk Score Predict Mortality and the Need for Thrombolytic Treatment in Acute Pulmonary Embolism?
2024, American Journal of Cardiology
Acute coronary syndrome and pulmonary embolism (PE) are clinical entities sharing similar presentation and risk factors. Risk scores and indexes help to identify disease severity in both diseases. In this study, we aimed to evaluate if the Global Registry of Acute Coronary Events (GRACE) risk score could predict 30-day mortality and the need for thrombolytic treatment in patients with acute PE. Patients hospitalized with a diagnosis of PE in our tertiary center between January 2018 and May 2022 were included in this retrospective study. Pulmonary Embolism Severity Index (PESI) and GRACE risk scores on admission were calculated using clinical, electrocardiographic, and laboratory parameters for each patient. A total of 197 patients were included. The 30-day mortality rate was 28.4% whereas 32.5% of the patients required thrombolytic treatment. GRACE and PESI scores were found independent risk factors associated with 30-day mortality and the need for thrombolytic treatment. A cut-off value of 160.5 for GRACE score was associated with 88.5% sensitivity and 89.4% specificity in prediction of 30-day mortality. In contrast, GRACE score had 61.0% sensitivity and 60.0% specificity in the prediction of the need for thrombolytic treatment when the cut-off value was 147. In conclusion, GRACE risk score has an effective discriminating power in determining the early mortality of patients with acute PE. The incidence of short-term PE-related mortality was significantly increased in patients with high GRACE risk scores. Concomitant use of GRACE and PESI risk scores may aid in defining patients with high-risk PE and help predict poor prognosis with high specificity and probability.
Update on the risk stratification of acute symptomatic pulmonary thromboembolism
2017, Revista Clinica Espanola
La mortalidad precoz en pacientes con tromboembolia pulmonar (TEP) varía desde el 2% en pacientes normotensos al 30% en pacientes con shock cardiogénico. La estratificación actual de riesgo en la TEP sintomática incluye 4 grupos de pacientes y las estrategias terapéuticas recomendadas se basan en dicha estratificación. Los pacientes que se presentan con inestabilidad hemodinámica se consideran de alto riesgo y en ellos se recomienda el tratamiento fibrinolítico. En pacientes normotensos, la estratificación de riesgo ayuda a diferenciar entre aquellos de bajo riesgo, riesgo intermedio-bajo y riesgo intermedio-alto. Actualmente no existe suficiente evidencia sobre el beneficio de una monitorización intensiva y tratamiento fibrinolítico en pacientes con riesgo intermedio-alto. En pacientes de bajo riesgo, está indicada la anticoagulación estándar y podría considerarse la posibilidad de un alta precoz con manejo ambulatorio, aunque su beneficio no está todavía firmemente establecido.
Early mortality in patients with pulmonary thromboembolism (PTE) varies from 2% in normotensive patients to 30% in patients with cardiogenic shock. The current risk stratification for symptomatic PTE includes 4 patient groups, and the recommended therapeutic strategies are based on this stratification. Patients who have haemodynamic instability are considered at high risk. Fibrinolytic treatment is recommended for these patients. In normotensive patients, risk stratification helps differentiate between those of low risk, intermediate-low risk and intermediate-high risk. There is currently insufficient evidence on the benefit of intensive monitoring and fibrinolytic treatment in patients with intermediate-high risk. For low-risk patients, standard anticoagulation is indicated. Early discharge with outpatient management may be considered, although its benefit has still not been firmly established.
Prognostic Value of Ventricular Wall Motion Score and Global Registry of Acute Coronary Events Score in Patients With Acute Myocardial Infarction
2017, American Journal of the Medical Sciences
Citation Excerpt :
A large number of clinical observations have verified its efficacy in the prediction of MACE after AMI. Accordingly, we used the GRACE score to successfully identify high-risk patients, which is consistent with previous studies.13-16 Nevertheless, certain concerns about the GRACE score have been raised.
The aim of this study was to evaluate the prognostic values of ventricular wall motion score (WMS) and Global Registry of Acute Coronary Events (GRACE) score in patients with acute myocardial infarction (AMI) in a 12-month single-center prospective cohort.
Consecutive inpatients diagnosed with AMI in the Department of Cardiology of The Second Affiliated Hospital of Soochow University from September 2012 through March 2015 were enrolled in this study. Echocardiography was issued to all subjects to calculate WMS within 24 hours after admission, and GRACE score of each patient was obtained simultaneously. During a 12-month follow-up period, all major adverse cardiac events (MACE) were recorded.
After 12 months of observation, 124 of 635 patients with AMI developed MACE. The WMS (23.70 ± 3.80 versus 20.47 ± 3.25) and GRACE score (185.59 ± 45.16 versus 152.19 ± 36.51) were significantly higher in patients with MACE than those without MACE (P < 0.05). Survival analysis using Cox regression revealed that both WMS (95% CI: 1.082-1.184, P < 0.05) and GRACE score (95% CI: 1.010-1.021, P < 0.05) independently predicted MACE. The receiver operating curve curve analysis showed that the area under curve of WMS, GRACE score and the combination of WMS and GRACE score were 0.768 (P < 0.05), 0.718 (P < 0.05) and 0.812 (P < 0.05), respectively.
WMS and GRACE score were independent predictors of MACE in patients with AMI in 12-month follow-up, and the combined application of WMS and GRACE score can significantly improve the predictive value.
Best Clinical Practice: Controversies in Outpatient Management of Acute Pulmonary Embolism
2017, Journal of Emergency Medicine
Citation Excerpt :
Sensitivity approaches 88%, with 23% to 36% of patients meeting low-risk criteria (34,58). The GRACE possesses a high diagnostic ability for adverse outcomes in patients with acute coronary syndrome; however, investigators have sought to use this score for PE risk stratification (59). The components of this score (Table 5) can be complex.
Pulmonary embolism (PE) is a common condition managed in the emergency department (ED), with a wide range of morbidity and mortality. Patients are classically admitted for treatment and monitoring of anticoagulation.
We sought to evaluate the controversy concerning outpatient therapy for patients with acute PE and investigate the feasibility, safety, and efficacy of outpatient management.
Patients with venous thromboembolism have historically been admitted for treatment and monitoring for concern of worsening disease or side effects of anticoagulation (bleeding). More than 90% of EDs admit patients with PE in the United States. However, close to 50% of patients may be appropriate for discharge and outpatient therapy. The published literature suggests that outpatient treatment is safe, feasible, and efficacious, with similar rates of recurrent venous thromboembolism and all-cause mortality, especially with novel oral anticoagulants. Multiple scoring criteria can be used, including the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva Prognostic Score, European Society of Cardiology guidelines, Global Registry of Acute Coronary Events, and Aujesky score. Simplified PESI and the European Society of Cardiology guidelines have high-quality evidence, sufficient sensitivity, and ease of use for the ED. Patients considered for outpatient therapy should possess low hemorrhage risk, adequate social situation, negative biomarkers, ability to comply, and no alternate need for admission.
Patients with acute PE are often admitted in the United States, but a significant proportion may be appropriate for discharge. Patients with low risk for adverse events according to clinical scoring criteria, adequate follow-up, ability to comply, and no other need for admission can be discharged with novel oral anticoagulant therapy.
Prognostic accuracy of clinical prediction rules for early post-pulmonary embolism all-cause mortality: A bivariate meta-analysis
2015, Chest
Citation Excerpt :
Of the 259 full-text eligible articles reviewed, 40 studies (reporting results of 52 unique patient cohort-clinical prediction rule analyses) reported mortality data for both low- and high-risk classified patients with aPE and were included in the meta-analysis7–46,60(Table 1). In total, we identified 11 different clinical prediction rules,7,8,17,19,21,23,27,35,61–64 with 36 studies reporting on one clinical prediction rule and four studies reporting data on two or more. e-Appendix 2 details the clinical parameters and scoring methods to determine prognosis in patients with aPE for each of the identified clinical prediction rules, along with a comparison of the parameters used in each tool.
BACKGROUND: Studies suggest outpatient treatment or early discharge of patients with acute pulmonary embolism (aPE) is reasonable for those deemed to be at low risk of early mortality. We sought to determine clinical prediction rule accuracy for identifying patients with aPE at low risk for mortality.
METHODS: We performed a literature search of Medline and Embase from January 2000 to March 2014, along with a manual search of references. We included studies deriving/validating a clinical prediction rule for early post-aPE all-cause mortality and providing mortality data over at least the index aPE hospitalization but ≤ 90 days. A bivariate model was used to pool sensitivity and specificity estimates using a random-effects approach. Traditional random-effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low risk for early mortality and their ORs for death compared with high-risk patients.
RESULTS: Forty studies (52 cohort-clinical prediction rule analyses) reporting on 11 clinical prediction rules were included. The highest sensitivities were observed with the Global Registry of Acute Coronary Events (0.99, 95% CI = 0.89-1.00), Aujesky 2006 (0.97, 95% CI = 0.95-0.99), simplified Pulmonary Embolism Severity Index (0.92, 95% CI = 0.89-0.94), Pulmonary Embolism Severity Index (0.89, 95% CI = 0.87-0.90), and European Society of Cardiology (0.88, 95% CI = 0.77-0.94) tools, with remaining clinical prediction rule sensitivities ranging from 0.41 to 0.82. Of these five clinical prediction rules with the highest sensitivities, none had a specificity > 0.48. They suggested anywhere from 22% to 45% of patients with aPE were at low risk and that low-risk patients had a 77% to 97% lower odds of death compared with those at high risk.
CONCLUSIONS: Numerous clinical prediction rules for prognosticating early mortality in patients with aPE are available, but not all demonstrate the high sensitivity needed to reassure clinicians.

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MiscellaneousCardiovascular Risk Assessment of Pulmonary Embolism With the GRACE Risk Score

Section snippets

Methods

Results

Discussion

Disclosures

J Thromb Haemost

Am Heart J

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

J Thromb Haemost

Guidelines on the diagnosis an management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

Eur Heart J

Predicting adverse outcome in patients with acute pulmonary embolism: a risk score

Thromb Haemost

Simplification of the Pulmonary Embolism Severity Index for prognostication in patients with acute symptomatic pulmonary embolism

Arch Intern Med

Haemodynamically unstable pulmonary embolism in the RIETE registry: systolic blood pressure or shock index

Eur Respir J

Miscellaneous
Cardiovascular Risk Assessment of Pulmonary Embolism With the GRACE Risk Score