Simplified PESI (Pulmonary Embolism Severity Index)
Why Use
The sPESI is a simpler version of the PESI that is easy to apply to patients who have been diagnosed with PE. In the derivation study it had a better negative predictive value than the PESI . It is simpler to use and comparable in accuracy.
When to Use
In the setting of a patient diagnosed with pulmonary embolism, the sPESI can be utilized to determine if he/she is a possible candidate for outpatient management. For those determined to be low risk (score of 0), mortality risk is 1.1%.
Formula
Pearls / Pitfalls
The Simplified Pulmonary Embolism Severity Index (sPESI) was designed to remove some of the more complicated elements of the Pulmonary Embolism Severity Index (PESI) and aid in the risk stratification of patients with pulmonary embolism (PE). The sPESI is easier to remember and simpler to use than its predecessor. The sPESI has been shown to be equally as accurate as, if not more than, the original PESI. The sPESI is a rule-out type of tool. ALL criteria must be answered “no” in order for the patient to be considered low-risk. The sPESI is meant to aid in decision making, not replace it. Clinical judgement should always take precedence. Patients determined to be low risk can be considered for outpatient management if clinical and social factors warrant it. About the PESI : 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.
Management
If the patient is considered low risk (score of 0) by the sPESI: Patient has an overall low risk of mortality (1.1%) or severe morbidity (1.5%). Consider outpatient management of PE if clinically appropriate and social factors allow for it. If the patient is considered high risk (score of ≥1) by the sPESI: Patient has an overall high risk of mortality (8.9%) or severe morbidity (2.7%). Consider inpatient management and higher levels of care if clinically appropriate.
Critical Actions
The sPESI is only meant for risk stratification of pulmonary embolism after the diagnosis has been made. The sPESI can not be used to risk stratify patients who are not being treated for PE. Additional pathology which could lead to morbidity or mortality should not be overlooked in the setting of low risk sPESI scores.
Advice
Social situation should be taken into account before considering outpatient management (including the appropriate administration of anticoagulants). Fewer patients were classified as low risk by sPESI than PESI , and the sPESI derivation cohort had patients with more comorbidities than the original. Given low mortality of low risk PE, outpatient management would save significant funds over hospitalization (cited as $4,500 per avoided admission).
More Information
Interpretation: Score Risk group Interpretation 0 points Low 1.1% risk of death, with 1.5% having recurrent thromboembolism or non-fatal bleeding ≥1 points High 8.9% risk of death From the derivation study : “This study shows that the simplified PESI successfully predicts 30-day mortality after acute symptomatic PE. Compared with the original PESI , the simplified PESI has similar prognostic accuracy. The simplified score had good discrimination and calibration, and an external data set validated the generalizability of its predictive accuracy.” Note: While the Simplified PESI was applied to a group of patients with data that was collected prospectively, the rule itself has not been validated in a newly-prospective cohort.