CHEST Guidelines-Response_chest

Response_chest_14

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The correspondence discusses the criteria for defining intermediate-risk pulmonary embolism (PE) and questions their current validity. Bradford and Farber express concern over the risk stratification provided by the 2008 European Society of Cardiology guidelines, which estimate early mortality risk for intermediate-risk PE at 3% to 15%. They reference several meta-analyses and the PEITHO trial, which do not support these predictions. Specifically, these studies indicate that echocardiography and cardiac biomarkers may not be reliable for assessing mortality risk in normotensive patients with PE. In the PEITHO trial, the predicted early mortality rate for intermediate-risk patients was 7%, yet observed mortality was only 1.8% for placebo recipients.<br /><br />In response, Doyen and Ferrari acknowledge the inconsistency in mortality predictions and note that their study observed a mortality rate of 2.4%, lower than expected. They highlight that the heterogeneity in risk among intermediate-risk patients may complicate accurate stratification. They reference a scoring system proposed by Bova et al., which uses variables like right ventricular dysfunction, elevated troponin, and specific blood pressure values to more accurately categorize mortality risk for PE patients.<br /><br />Doyen and Ferrari suggest that improved management of PE cases (including continuous monitoring in ICUs and advancements in global management post-2008 guidelines) might have contributed to decreased mortality rates. They propose that screening for patent foramen ovale (PFO) could aid in determining the suitability of fibrinolysis treatment, as a PFO is linked to higher stroke risk and potential complications from such therapy. They argue for consideration of PFO screening to optimize fibrinolysis candidates, referencing that PFO presence aligns with risks found in PEITHO where hemorrhagic events played a key role in treatment outcomes.

Keywords

intermediate-risk pulmonary embolism

mortality risk

European Society of Cardiology guidelines

PEITHO trial

echocardiography

cardiac biomarkers

risk stratification

Bova scoring system

patent foramen ovale

fibrinolysis treatment