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Derivation and Validation of a Prognostic Model for Pulmonary Embolism

Division of General Internal Medicine, Clinical Epidemiology Center, and the University Outpatient Clinic, University of Lausanne, Lausanne; Division of General Internal Medicine, Department of Internal Medicine, University of Geneva, Geneva, Switzerland; Division of General Internal Medicine, Department of Medicine; Department of Biostatistics, Graduate School of Public Health; Department of Emergency Medicine, University of Pittsburgh; VA Center for Health Equity Research and Promotion, and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and Department of Emergency Medicine, University of Angers, Angers, France

Correspondence and requests for reprints should be addressed to Drahomir Aujesky, M.D., M.Sc., Service de Médecine Interne, BH10-622, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland. E-mail: drahomir.aujesky{at}chuv.ch

Rationale: An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment.

Objectives: To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes.

Methods: We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our prediction rule using logistic regression with 30-day mortality as the primary outcome, and patient demographic and clinical data routinely available at presentation as potential predictor variables. We externally validated the rule in 221 inpatients with pulmonary embolism from Switzerland and France.

Measurements: We compared mortality and nonfatal adverse medical outcomes across the derivation and two validation samples.

Main Results: The prediction rule is based on 11 simple patient characteristics that were independently associated with mortality and stratifies patients with pulmonary embolism into five severity classes, with 30-day mortality rates of 0–1.6% in class I, 1.7–3.5% in class II, 3.2–7.1% in class III, 4.0–11.4% in class IV, and 10.0–24.5% in class V across the derivation and validation samples. Inpatient death and nonfatal complications were 1.1% among patients in class I and 1.9% among patients in class II.

Conclusions: Our rule accurately classifies patients with pulmonary embolism into classes of increasing risk of mortality and other adverse medical outcomes. Further validation of the rule is important before its implementation as a decision aid to guide the initial management of patients with pulmonary embolism.

Key Words: mortality • prognosis • pulmonary embolism

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