Clinical gestalt versus prognostic scores for prognostication of patients with acute symptomatic pulmonary embolism

• Published in: Medicina clinica Vol. 151; no. 4; p. 136
• Main Authors: Quezada, Carlos Andrés, Zamarro, Celia, Gómez, Vicente, Guerassimova, Ina, Nieto, Rosa, Barbero, Esther, Chiluiza, Diana, Barrios, Deisy, Morillo, Raquel, Jiménez, David
• Format: Journal Article
• Language: English; Spanish
• Published: Spain 22-08-2018
• Subjects: Acute Disease; Aged; Cause of Death; Clinical Competence; Confidence Intervals; Female; Humans; Internship and Residency; Male; Prognosis; Pulmonary Embolism - diagnostic imaging; Pulmonary Embolism - mortality; Pulmonary Embolism - therapy; Pulmonary Medicine; Risk Assessment; Severity of Illness Index; Symptom Assessment; Time Factors; Escalas pronósticas; Pulmonary embolism; Tromboembolia de pulmón; Prognosis; Pronóstico; Mortality; Mortalidad; Prognostic scales; Evaluación empírica; Clinical assessment
• ISSN: 1578-8989
• DOI: 10.1016/j.medcli.2017.11.023

To determine the accuracy of clinical gestalt to identify patients with acute symptomatic pulmonary embolism (PE) at low-risk for short-term complications.
This study included a total of 154 consecutive patients diagnosed with acute symptomatic PE in a tertiary university hospital. We compared the prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and clinical gestalt of 1) 2senior physicians (one with and one without experience in the management of patients with PE), 2) a fourth-year resident of Pneumology, 3) a third-year resident of Pneumology, and 4) a second-year resident of Pneumology. The primary outcome was all-cause mortality during the first month after the diagnosis of PE.
Thirty-day all-cause mortality was 8.4% (13/154; 8.4%; 95% confidence interval [CI], 4.1-12.8%). The PESI and clinical gestalt classified more patients as low-risk, compared to the sPESI (36.4%, 31.3% y 28.6%, respectively). There were no deaths in the sPESI low-risk category (negative predictive value 100%). Prognostic accuracy increased with increasing experience (84.6 vs. 92.3%; P=.049).
The sPESI showed the best accuracy at correctly identifying low-risk patients with acute symptomatic PE. Clinical gestalt is not inferior to standardized clinical prediction rules to prognosticate patients with acute PE.