National Early Warning Score for Predicting Clinical Outcome of Acute Pulmonary Embolism in Intermediate–High Risk Patients

Abstract

Background

Although the European Society of Cardiology (ESC) predicts mortality in acute pulmonary embolism (PE), it may overtriage the level of clinical monitoring needed. The National Early Warning Score (NEWS) is used to triage level of care in many diseases, but it is rarely reported in PE literature.

Methods

In this retrospective, single-center, observational cohort study of consecutive adults with acute PE, between 2017 and 2020, we aim to assess the association between NEWS and the risk of hemodynamic (HD) deterioration or PE-related death in intermediate–high risk PE patients. The NEWS at admission and after 24 hours were determined. A baseline NEWS of ≥5 or the maximum score of a single parameter was considered an indication of high risk of our primary outcome (hemodynamic deterioration and/or PE-related mortality).

Results

ESC classified 99 of 318 patients with PE as intermediate–high risk; 8 patients (8%) met the primary outcome. A total of 52 (52%) patients had an elevated NEWS and 7 of these met the primary outcome (13%), while only 1 patient with a non-elevated NEWS (2.0%) met the primary outcome (negative predictive value of 98%; 95% CI 90–98%). Sensitivity of elevated NEWS in patients with intermediate–high risk was 88% (95% CI 74–90%) and the specificity was 51% (95% CI 41–61%).

Conclusion

Using NEWS in intermediate–high risk, acute PE patients may improve accuracy in identifying patients with a higher risk of adverse outcomes and may guide the decision to monitor a patient in a high-care department, especially in patients with intermediate–high risk PE.

Keywords

pulmonary thromboembolism - risk assessment - critical care - early warning score

• References

• 1 Barco S, Mahmoudpour SH, Valerio L. et al. Trends in mortality related to pulmonary embolism in the European Region, 2000-15: analysis of vital registration data from the WHO Mortality Database. Lancet Respir Med 2020; 8 (03) 277-287
• 2 Konstantinides SV, Torbicki A, Agnelli G. et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (43) 3033-3069 3069a–3069k
• 3 Konstantinides SV, Meyer G. The 2019 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2019; 40 (42) 3453-3455
• 4 van der Meer RW, Pattynama PM, van Strijen MJ. et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology 2005; 235 (03) 798-803
• 5 Lankeit M, Friesen D, Aschoff J. et al. Highly sensitive troponin T assay in normotensive patients with acute pulmonary embolism. Eur Heart J 2010; 31 (15) 1836-1844
• 6 Klok FA, Mos ICM, Huisman MV. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Am J Respir Crit Care Med 2008; 178 (04) 425-430
• 7 Klok FA, Djurabi RK, Nijkeuter M. et al. High D-dimer level is associated with increased 15-d and 3 months mortality through a more central localization of pulmonary emboli and serious comorbidity. Br J Haematol 2008; 140 (02) 218-222
• 8 Huisman MV, Barco S, Cannegieter SC. et al. Pulmonary embolism. Nat Rev Dis Primers 2018; 4: 18028
• 9 Klok FA, Meyer G, Konstantinides S. Management of intermediate-risk pulmonary embolism: uncertainties and challenges. Eur J Haematol 2015; 95 (06) 489-497
• 10 Meyer G, Vicaut E, Danays T. et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
• 11 Klok FA, Toenges G, Mavromanoli AC. et al; PEITHO-2 investigators. Early switch to oral anticoagulation in patients with acute intermediate-risk pulmonary embolism (PEITHO-2): a multinational, multicentre, single-arm, phase 4 trial. Lancet Haematol 2021; 8 (09) e627-e636
• 12 World Health Organization Regional Office for Europe. Appropriateness in health care services: report on a WHO workshop, Koblenz, Germany, 23–25 March 2000. Copenhagen: WHO Regional Office for Europe; 2000
• 13 Robertson-Preidler J, Biller-Andorno N, Johnson TJ. What is appropriate care? An integrative review of emerging themes in the literature. BMC Health Serv Res 2017; 17 (01) 452
• 14 Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation 2013; 84 (04) 465-470
• 15 Gerry S, Bonnici T, Birks J. et al. Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology. BMJ 2020; 369: m1501
• 16 Nannan Panday RS, Minderhoud TC, Alam N, Nanayakkara PWB. Prognostic value of early warning scores in the emergency department (ED) and acute medical unit (AMU): a narrative review. Eur J Intern Med 2017; 45: 20-31
• 17 Overgaauw A, Meijboom LJ, van Es J. et al. Real-world characteristics and outcomes of patients with intermediate high risk acute pulmonary embolism. Acute Med 2023; 22 (02) 61-66
• 18 Le Gal G, Carrier M, Castellucci LA. et al; ISTH CDE Task Force. Development and implementation of common data elements for venous thromboembolism research: on behalf of SSC Subcommittee on official Communication from the SSC of the ISTH. J Thromb Haemost 2021; 19 (01) 297-303
• 19 Royal College of Physicians. National Early Warning Score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: Royal College of Physicians; 2017
• 20 Bavalia R, Stals MAM, Mulder FI. et al. Use of the National Early Warning Score for predicting deterioration of patients with acute pulmonary embolism: a post-hoc analysis of the YEARS Study. Emerg Med J 2023; 40 (01) 61-66
• 21 Leenen JPL, Leerentveld C, van Dijk JD, van Westreenen HL, Schoonhoven L, Patijn GA. Current evidence for continuous vital signs monitoring by wearable wireless devices in hospitalized adults: systematic review. J Med Internet Res 2020; 22 (06) e18636