What is the management approach for patients with pulmonary embolism (PE) based on the Pulmonary Embolism Severity Index (PESI) guideline?

Management of Pulmonary Embolism Based on PESI Guidelines

Patients with pulmonary embolism should be risk-stratified using the Pulmonary Embolism Severity Index (PESI) or simplified PESI (sPESI) to determine appropriate management setting, with low-risk patients (PESI class I/II or sPESI 0) eligible for outpatient treatment when additional exclusion criteria are met. 1

Risk Stratification Tools

Original PESI Score

• PESI was derived and validated using a cohort of 15,752 patients with confirmed PE 1
• Classifies patients into five risk classes (I-V) based on 30-day mortality risk 1
• PESI classes I (very low risk) and II (low risk) had 30-day mortality rates of ≤1.6% and 3.6%, respectively 1
• Demonstrates excellent discriminatory power with area under the ROC curve of 0.77-0.87 1, 2

Simplified PESI (sPESI)

• Consists of six variables with binary scoring (0 or 1 point for each variable) 1
• A score of zero classifies patients as low risk 1
• Low-risk patients (sPESI=0) had 30-day mortality of 1.0-1.1% 1
• Non-inferior to original PESI for predicting mortality, though original PESI has slightly greater discriminatory power 2

Comparison of PESI vs sPESI

• Original PESI classifies more patients as low-risk than sPESI (40.9% vs. 36.8%) 2
• Both have similar sensitivities (90% vs. 89%) and negative predictive values (98% vs. 97%) for predicting mortality 2
• Inter-rater reliability for PESI is excellent, with near-perfect agreement for risk classification (κ: 0.92) 3

Management Algorithm Based on PESI/sPESI

Step 1: Risk Stratification

• Calculate PESI or sPESI score for all patients with confirmed PE 1
• Classify patients as low risk (PESI class I/II or sPESI=0) or higher risk (PESI class III-V or sPESI≥1) 1

Step 2: Evaluate for Exclusion Criteria for Outpatient Management

For low-risk patients, assess for the following exclusion criteria 1:

• Hemodynamic instability (HR>110bpm, SBP<100mmHg, need for inotropes/critical care) 1
• Oxygen saturation <90% on room air 1
• Active bleeding or high risk of major bleeding 1
• Already on full-dose anticoagulation at time of PE diagnosis 1
• Severe pain requiring opiates 1
• Medical comorbidities requiring hospitalization 1
• Severe renal impairment (CKD stages 4-5) or severe liver disease 1
• History of heparin-induced thrombocytopenia within past year 1
• Social factors (inadequate home care, lack of telephone communication, compliance concerns) 1

Step 3: Management Decision

• Low-risk patients (PESI I/II or sPESI=0) without exclusion criteria: Offer outpatient management 1
• Intermediate-risk patients (PESI III or higher): Consider inpatient management 1
• High-risk patients (hemodynamically unstable): Require inpatient management with consideration of thrombolysis 1

Step 4: Additional Assessment for Borderline Cases

• For patients with low PESI/sPESI but evidence of right ventricular (RV) dysfunction on imaging, consider measuring cardiac biomarkers 1
• Normal biomarkers may confirm low-risk status; elevated biomarkers should prompt inpatient admission 1
• Patients initially admitted with intermediate risk can be considered for early discharge when they meet low-risk criteria 1

Treatment Recommendations for Outpatient Management

• Outpatients with confirmed PE should receive either 1:
  • LMWH and dabigatran
  • LMWH and edoxaban
  • Single-drug regimen (apixaban or rivaroxaban)
• Using a single DOAC in a pathway is preferred to minimize confusion over dosing 1

Implementation Considerations

• Studies show 33.7-49.7% of PE patients may qualify for outpatient management based on risk scores, but these tools are underutilized in clinical practice 4, 5
• Patients managed as outpatients report high satisfaction rates (65-96% highly satisfied) 1
• A robust pathway for follow-up and monitoring must exist for outpatient management 1
• Patients with suspected PE should ideally undergo same-day investigation 1
• All patients considered for outpatient management should be reviewed by a consultant or appropriate senior clinician before discharge 1

Special Considerations

• Pregnant and postpartum women require consultant review and discussion with maternity services prior to discharge 1
• Clinical risk scores like PESI/sPESI should not be used in pregnant patients 1
• DOACs or vitamin K antagonists should not be used during pregnancy 1
• Follow-up should be performed by clinicians with special interest in venous thromboembolism 1