CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism
Abstract
:1. Introduction
2. Methods
2.1. Study Endpoints and In-Hospital Adverse Events
2.2. Definitions
2.3. Ethical Aspects and Study Oversight
2.4. Statistics
3. Results
4. Discussion
- (i)
- Annual numbers of PE cases increased slowly from 2005 to 2020.
- (ii)
- The proportion of high-risk patients according to the CRB-65 score (≥1 points) was widely stable over time.
- (iii)
- Established risk stratification parameters such as syncope and right ventricular dysfunction, as well as tachycardia and sPESI, were more prevalent in the high-risk patients according to the CRB-65 score (≥1 points).
- (iv)
- In-hospital case fatality rate was 15.6%, and MACCE rate 17.3% higher in PE patients of the high-risk group according to the CRB-65 score (≥1 points) compared to the low-risk group (= 0 points). In addition, stroke, acute kidney injury, pneumonia, and all bleeding events occurred more often in the high-risk group according to the CRB-65 score (≥1 points).
- (v)
- Systemic thrombolysis as well as surgical embolectomy were both more often used in the high-risk vs. low-risk group defined according to the CRB-65 score.
- (vi)
- An increase in CRB-65 score by 1 was independently related to a 3.8-fold higher risk for in-hospital death and a 3.4-fold higher risk for MACCE.
- (vii)
- The CRB-65 high-risk class was independently and strongly associated with in-hospital death as well as MACCE.
- (viii)
- The prognostic performance of the CRB-65 score was better as sPESI, wherby the sPESI was developed for risk stratification of haemodynamically stable PE patients.
- (ix)
- Systemic thrombolysis and surgical embolectomy were both independently more often used in the CRB-65 high-risk group.
- (x)
- The CRB-65 high-risk group was also independently associated with all bleeding events.
5. Limitations
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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CRB-65 Point Score | ICD or OPS Codes | |
---|---|---|
Confusion | +1 point | ICD code R40 |
Respiratory failure | +1 point | ICD code J96 and/or OPS codes 8–71 or 8–72 |
Unstable pulmonary embolism (CPR or shock) | +1 point | ICD code R57 and/or OPS code 8–77 |
Age ≥65 years | +1 point | |
Graduation of patients according to CRB-65 score:
|
Parameters | PE Patients with CRB-65 Score = 0 (n = 321,901; 23.4%) | PE Patients with CRB-65 Score ≥ 1 (n = 1,051,244; 76.6%) | p-Value |
---|---|---|---|
Age | 53.0 (44.0–59.0) | 76.0 (69.0–82.0) | <0.001 |
Age ≥65 years | 0 (0.0%) | 921,165 (87.6%) | <0.001 |
Female sex * | 140,497 (43.6%) | 586,987 (55.8%) | <0.001 |
In-hospital stay (days) | 7.0 (4.0–12.0) | 10.0 (6.0–17.0) | <0.001 |
Traditional cardiovascular risk factors | |||
Obesity | 35,267 (11.0%) | 95,375 (9.1%) | <0.001 |
Essential arterial hypertension | 91,902 (28.5%) | 510,857 (48.6%) | <0.001 |
Diabetes mellitus | 30,219 (9.4%) | 226,017 (21.5%) | <0.001 |
Hyperlipidaemia | 24,257 (7.5%) | 147,887 (14.1%) | <0.001 |
Classical risk factors for venous thromboembolism and proportion of DVT | |||
Cancer | 68,567 (21.3%) | 210,606 (20.0%) | <0.001 |
Any surgery | 154,930 (48.1%) | 556,953 (53.0%) | <0.001 |
Thrombophilia | 7853 (2.4%) | 8218 (0.8%) | <0.001 |
Deep venous thrombosis or thrombophlebitis | 138,595 (43.1%) | 350,439 (33.3%) | <0.001 |
Comorbidities | |||
Charlson comorbidity index | 2.0 (0.0–3.0) | 5.0 (4.0–7.0) | <0.001 |
Coronary artery disease | 16,262 (5.1%) | 171,331 (16.3%) | <0.001 |
Heart failure | 24,245 (7.5%) | 276,552 (26.3%) | <0.001 |
Peripheral artery disease | 4092 (1.3%) | 35,586 (3.4%) | <0.001 |
Atrial fibrillation/flutter | 12,069 (3.7%) | 194,995 (18.5%) | <0.001 |
Chronic obstructive pulmonary disease | 14,190 (4.4%) | 124,215 (11.8%) | <0.001 |
Acute and chronic kidney disease | 19,514 (6.1%) | 274,962 (26.2%) | <0.001 |
Risk stratification markers of VTE | |||
Unstable PE (CPR or shock) | 0 (0.0%) | 123,180 (11.7%) | <0.001 |
Shock | 0 (0.0%) | 56,644 (5.4%) | <0.001 |
Syncope | 4673 (1.5%) | 28,643 (2.7%) | <0.001 |
Right ventricular dysfunction | 54,433 (16.9%) | 326,828 (31.1%) | <0.001 |
Tachycardia | 6955 (2.2%) | 33,964 (3.2%) | <0.001 |
Respiratory failure | 0 (0.0%) | 394,858 (37.6%) | <0.001 |
Confusion | 0 (0.0%) | 25,385 (2.4%) | <0.001 |
sPESI ≥1 (sPESI high-risk class) | 113,092 (35.1%) | 741,874 (70.6%) | <0.001 |
Adverse events during hospitalization | |||
In-hospital death | 10,874 (3.4%) | 199,702 (19.0%) | <0.001 |
MACCE | 16,318 (5.1%) | 235,908 (22.4%) | <0.001 |
Systemic thrombolysis | 6645 (2.1%) | 50,532 (4.8%) | <0.001 |
Surgical embolectomy | 417 (0.13%) | 1593 (0.15%) | 0.004 |
Pneumonia | 73,215 (22.7%) | 257,620 (24.5%) | <0.001 |
Acute kidney injury | 5423 (1.7%) | 84,936 (8.1%) | <0.001 |
Stroke (ischaemic or haemorrhagic) | 4816 (1.5%) | 35,764 (3.4%) | <0.001 |
Intracerebral bleeding | 1034 (0.3%) | 7531 (0.7%) | <0.001 |
Gastrointestinal bleeding | 2335 (0.7%) | 18,594 (1.8%) | <0.001 |
Transfusion of blood constituents | 21,462 (6.7%) | 138,194 (13.1%) | <0.001 |
Univariable Regression Model | Multivariable Regression Model * | |||
---|---|---|---|---|
OR (95% CI) | p-Value | OR (95% CI) | p-Value | |
In-hospital death | 3.72 (3.69–3.74) | <0.001 | 3.81 (3.79–3.84) | <0.001 |
MACCE | 3.37 (3.35–3.39) | <0.001 | 3.35 (3.32–3.37) | <0.001 |
Pneumonia | 1.28 (1.27–1.28) | <0.001 | 1.45 (1.44–1.45) | <0.001 |
Acute kidney injury | 2.96 (2.94–2.99) | <0.001 | 2.37 (2.34–2.39) | <0.001 |
Stroke (ischaemic or haemorrhagic) | 1.70 (1.69–1.72) | <0.001 | 1.77 (1.74–1.79) | <0.001 |
Intracerebral bleeding | 1.89 (1.85–1.94) | <0.001 | 2.35 (2.29–2.42) | <0.001 |
Gastrointestinal bleeding | 1.72 (1.69–1.75) | <0.001 | 1.51 (1.48–1.54) | <0.001 |
Transfusion of blood constituents | 1.89 (1.87–1.90) | <0.001 | 2.04 (2.02–2.05) | <0.001 |
Univariable Regression Model | Multivariable Regression Model * | |||
---|---|---|---|---|
OR (95% CI) | p-Value | OR (95% CI) | p-Value | |
In-hospital death | 6.71 (6.58–6.84) | <0.001 | 5.53 (5.40–5.65) | <0.001 |
MACCE | 5.42 (5.33–5.51) | <0.001 | 4.31 (4.23–4.40) | <0.001 |
Right ventricular dysfunction | 2.22 (2.20–2.24) | <0.001 | 2.42 (2.39–2.45) | <0.001 |
Systemic thrombolysis | 2.40 (2.33–2.46) | <0.001 | 5.39 (5.23–5.55) | <0.001 |
Surgical embolectomy | 1.17 (1.05–1.30) | <0.001 | 3.15 (2.79–3.56) | <0.001 |
Pneumonia | 1.10 (1.09–1.11) | <0.001 | 1.49 (1.47–1.51) | <0.001 |
Acute kidney injury | 5.13 (4.99–5.27) | <0.001 | 2.97 (2.86–3.09) | <0.001 |
Stroke (ischaemic or haemorrhagic) | 2.32 (2.25–2.39) | <0.001 | 2.49 (2.40–2.58) | <0.001 |
Intracerebral bleeding | 2.24 (2.10–2.39) | <0.001 | 3.97 (3.68–4.28) | <0.001 |
Gastrointestinal bleeding | 2.46 (2.36–2.57) | <0.001 | 1.89 (1.79–1.99) | <0.001 |
Transfusion of blood constituents | 2.12 (2.09–2.15) | <0.001 | 2.75 (2.70–2.81) | <0.001 |
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Keller, K.; Schmitt, V.H.; Sagoschen, I.; Münzel, T.; Espinola-Klein, C.; Hobohm, L. CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism. J. Clin. Med. 2023, 12, 1264. https://doi.org/10.3390/jcm12041264
Keller K, Schmitt VH, Sagoschen I, Münzel T, Espinola-Klein C, Hobohm L. CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism. Journal of Clinical Medicine. 2023; 12(4):1264. https://doi.org/10.3390/jcm12041264
Chicago/Turabian StyleKeller, Karsten, Volker H. Schmitt, Ingo Sagoschen, Thomas Münzel, Christine Espinola-Klein, and Lukas Hobohm. 2023. "CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism" Journal of Clinical Medicine 12, no. 4: 1264. https://doi.org/10.3390/jcm12041264