National Early Warning Score-2 for Identification of Patients with Intermediate-High-Risk Pulmonary Embolism

Abstract

Consensus statements have proposed the use of the National Early Warning Score 2 (NEWS2) to identify stable patients with acute pulmonary embolism (PE) and an intermediate-high risk of adverse outcomes. We aimed to externally validate NEWS2 and compare it to another predictive score (Bova). Using NEWS2 (cutoff ≥5 and ≥7) and the Bova score (cutoff >4), we classified patients as intermediate-high risk (vs. non-intermediate-high risk), and we compared the test characteristics of these risk classification tools for a complicated course within 30 days after PE diagnosis. We also assessed the validity of NEWS2 for predicting a complicated course by adding the results of echocardiography and troponin testing to the model. Of the 848 enrolled patients, the NEWS2 score ≥5 classified 471 (55.5%) and the Bova score classified 37 (4.4%) as intermediate-high risk. NEWS2 had a significantly lower specificity for a 30-day complicated course than Bova (45.4 vs. 96.3%, respectively; p < 0.001). Using the higher score threshold (≥7), the NEWS2 classified 99 (11.7%) as intermediate-high risk, and the specificity was 88.9% (difference with Bova, 7.4%; p < 0.001). The proportion of patients with intermediate-high risk PE was 2.4% for the combination of a positive troponin testing and echocardiographic right ventricle dysfunction and a positive NEWS2 (score ≥7), while the specificity was 97.8% (difference with Bova, 1.5%; p = 0.07). Bova outperforms NEWS2 for predicting a complicated course among stable patients with PE. Addition of troponin testing and echocardiography improved the specificity of NEWS2, although it was not superior to Bova.

ClinicalTrials.gov number: NCT02238639.

Keywords

pulmonary embolism - prognosis - survival - scores

Authors' Contributions

Concept and design: C.R., D.J.

Acquisition, analysis, or interpretation of data; statistical analysis: C.R., A.M., L.C., S.G., W.B., D.D., A.R., R.Y., B.B., D.J.

Drafting of the manuscript: C.R., R.Y., B.B., D.J.

Obtained funding: D.J.

Study supervision: D.J.

D.J. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Data Sharing Statement

The datasets generated or analyzed during the current study are available from the corresponding author on reasonable request.

Publication History

Article published online:
16 June 2023

• References

• 1 Konstantinides SV, Torbicki A, Agnelli G. et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (43) 3033-3069 , 3069a–3069k
• 2 Stevens SM, Woller SC, Baumann Kreuziger L. et al. Executive summary: antithrombotic therapy for VTE disease: second update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160 (06) 2247-2259
• 3 Aujesky D, Roy PM, Verschuren F. et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378 (9785): 41-48
• 4 Roy PM, Penaloza A, Hugli O. et al; HOME-PE Study Group. Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial. Eur Heart J 2021; 42 (33) 3146-3157
• 5 Lobo JL, Alonso S, Arenas J. et al; en Nombre del Panel Multidisciplinar para el Manejo de la TEP. Multidisciplinary consensus for the management of pulmonary thromboembolism. Arch Bronconeumol 2022; 58 (03) 246-254
• 6 Giri J, Sista AK, Weinberg I. et al. Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: a scientific statement from the American Heart Association. Circulation 2019; 140 (20) e774-e801
• 7 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
• 8 Bova C, Sanchez O, Prandoni P. et al. Identification of intermediate-risk patients with acute symptomatic pulmonary embolism. Eur Respir J 2014; 44 (03) 694-703
• 9 Fernández C, Bova C, Sanchez O. et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism. Chest 2015; 148 (01) 211-218
• 10 Bova C, Vigna E, Gentile M, Pignataro FS. Comparison of two scores in predicting pulmonary embolism-related adverse events in intermediate-high-risk patients: a systematic review and meta-analysis. Intern Emerg Med 2022; 17 (05) 1543-1546
• 11 Royal College of Physicians. National Early Warning Score (NEWS): Standardising the Assessment of Acute-Illness Severity in the NHS. RCP, 2012. Accessed January 10, 2023 at: www.rcplondon.ac.uk/file/9559/download
• 12 Royal College of Physicians. National Early Warning Score (NEWS) 2. RCP, 2017. Accessed January 10, 2023 at: www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2
• 13 Alam N, Hobbelink EL, van Tienhoven AJ, van de Ven PM, Jansma EP, Nanayakkara PWB. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation 2014; 85 (05) 587-594
• 14 Keep JW, Messmer AS, Sladden R. et al. National early warning score at emergency department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study. Emerg Med J 2016; 33 (01) 37-41
• 15 Pruszczyk P, Klok FA, Kucher N. et al. Percutaneous treatment options for acute pulmonary embolism: a clinical consensus statement by the ESC Working Group on Pulmonary Circulation and Right Ventricular Function and the European Association of Percutaneous Cardiovascular Interventions. EuroIntervention 2022; 18 (08) e623-e638
• 16 Jiménez D, Kopecna D, Tapson V. et al; On Behalf of the Protect Investigators. Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism. Am J Respir Crit Care Med 2014; 189 (06) 718-726
• 17 Jiménez D, Lobo JL, Monreal M, Otero R, Yusen RD. Prognostic significance of multidetector computed tomography in normotensive patients with pulmonary embolism: rationale, methodology and reproducibility for the PROTECT study. J Thromb Thrombolysis 2012; 34 (02) 187-192
• 18 Agresti A, Min Y. Simple improved confidence intervals for comparing matched proportions. Stat Med 2005; 24 (05) 729-740
• 19 Yolcu S, Kaya A, Yilmaz N. Prediction of prognosis and outcome of patients with pulmonary embolism in the emergency department using early warning scores and qSOFA score. J Int Med Res 2022; 50 (10) 3000605221129915
• 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 Rodríguez C, Durán D, Retegui A. et al. Usefulness of the National Early Warning Score for risk stratification of stable patients with acute symptomatic pulmonary embolism. Arch Bronconeumol 2023; 59 (03) 152-156
• 22 Hobohm L, Becattini C, Konstantinides SV, Casazza F, Lankeit M. Validation of a fast prognostic score for risk stratification of normotensive patients with acute pulmonary embolism. Clin Res Cardiol 2020; 109 (08) 1008-1017
• 23 Mirambeaux R, Rodríguez C, Muriel A. et al. Comparison of various prognostic scores for identification of patients with intermediate-high risk pulmonary embolism. Thromb Res 2023; 223: 61-68