PESI Score for Pulmonary Embolism

Pulmonary Embolism Severity Index (PESI) score calculation

Finding	Points
Age	+1 per year
Male gender	+10
Cancer (history of or active)	+30
Heart failure	+10
Chronic lung disease	+10
Pulse ≥110 beats per min	+20
SBP <100 mmHg	+30
RR ≥30 breaths per min	+20
Temperature <36C	+20
Altered mental status	+60
Arterial oxygen saturation <90%	+20

Class	Point Total
I	<66
II	66-85
III	86-105
IV	106-125
V	>125

Outpatient Treatment of Pulmonary Embolism (OTPE) trial

Study design

Randomized, prospective, non-inferiority clinical trial of 19 ED’s (n = 344 patients) in Switzerland, France, Belgium, and USA looking at morbidity/mortality of PESI class I and II patients

Exclusion criteria from study

• Arterial hypoxemia (O2 saturation <90% on room air, or paO2 <60 mmHg)
• SBP <100 mmHg
• Chest pain necessitating parental opioids
• Active bleeding
• High risk of bleeding defined as: CVA during preceding 10 days, GI bleeding in preceding 14 days, or platelets <75K
• Severe renal failure (CrCl <30 mL per min)
• Extreme obesity (body mass >150 kg)
• History of heparin-induced thrombocytopenia or allergy to heparins
• Therapeutic oral anticoagulation at time of PE diagnosis (INR ≥2)
• Any barriers to treatment adherence (current EtOH abuse, illicit drug use, psychosis, dementia, homelessness)
• Pregnancy
• Imprisonment
• Diagnosis of PE >23 hrs before time of screening

Results

• Complication rates were calculated based on whether PE was managed as an outpatient or inpatient.

Complications	Outpatient	Inpatient
Major bleeding at ≤14 days	1.2% (2/171)	0% (0/168)
Major bleeding at ≤90 days	1.8% (1/171)	0% (0/168)
Recurrent venous thromboembolism at ≤90 days	0.6% (1/171)	0% (0/168)
Death at ≤90 days	0.6% (1/171)	0.6% (1/168)

Outpatient treatment

Enoxaparin 1 mg/kg SQ BID to bridge into PO warfarin (target INR=2)

Conclusion

PE patients with PESI class I or II seem safe to manage as outpatients.

• Be aware of exclusion criteria from study

References

• Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, Renaud B, Verhamme P, Stone RA, Legall C, Sanchez O, Pugh NA, N'gako A, Cornuz J, Hugli O, Beer HJ, Perrier A, Fine MJ, Yealy DM. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011 Jul 2;378(9785):41-8. doi: 10.1016/S0140-6736(11)60824-6. [PubMed]