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    Pulmonary Embolism Severity Index (PESI)

    Predicts 30-day outcome of patients with pulmonary embolism using 11 clinical criteria.
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    When to Use
    Pearls/Pitfalls
    Why Use

    In the setting of a patient diagnosed with PE, the PESI can be utilized to determine mortality and long term morbidity. For those determined to be very low risk (score ≤ 65), all studies showed a 30-day mortality <2%. In the validation, low risk (Class I and II) had a 90-day mortality of 1.1%. The non-inferiority trial demonstrated Class I and II could have been treated as outpatients assuming no other issues.

    The Pulmonary Embolism Severity Index (PESI) is a risk stratification tool that has been externally validated to determine the mortality and outcome of patients with newly diagnosed pulmonary embolism (PE).

    In the setting of a patient with renal failure or severe comorbidities, clinical judgement should be used over the PESI, as these patients were excluded in the validation study.

    • The PESI score determines risk of mortality and severity of complications.
    • The score does not require laboratory variables.
    • It is meant to aid in decision making, not replace it. Clinical judgement should always take precedence.
    • The PESI score determines clinical severity and can influence treatment setting for management of PE.
      • Class I and II patients may possibly be safely treated as outpatients in the right clinical setting.

    The PESI is designed to risk stratify patients who have been diagnosed with a PE in order to determine the severity of their disease. This can help physicians make decisions on the management of those patients who could potentially be treated as out-patient, as well as raise concern for those who are determined to be high-risk and could benefit from higher levels of care.

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    Advice

    • Social situation should also be taken into account before considering outpatient management (including the appropriate administration of anticoagulants).
    • Given low mortality of low risk PE, outpatient management would save significant funds over hospitalization (cited as $4,500 per avoided admission).
    • The non-inferiority trial showed successful and safe outpatient management of Class I and II patients.

    Management

    • If the patient is considered very low (≤ 65) or low risk (66-85) by the PESI score.
      • Patient has an overall low risk of mortality or severe morbidity.
      • Consider outpatient management of PE if clinically appropriate and social factors allow for it.
    • If the patient is considered intermediate (86-105), high risk (106-125) or very high risk (>125) by the PESI.
      • Patient has an overall high risk of mortality and severe morbidity.
      • Consider higher levels of care (e.g., ICU) for those with higher scores.

    Critical Actions

    • The PESI is only meant for risk stratification of pulmonary embolism after the diagnosis has been made.
    • Findings which could point toward clinically significant PE should not be overlooked in the setting of a low PESI score.
    • Additional pathology which could lead to morbidity or mortality should not be overlooked in the setting of a low PESI score.
    • All results for the validation of the PESI were made with patients who were treated for PE initially with enoxaparin, and then encouraged to transition to vitamin K antagonists.
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    About the Creator
    Dr. Drahomir Aujesky
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