Prognostic performance of composite PE shock score in comparison and combination with PESI and ESC risk classification: a retrospective cohort study

Abstract

PESI and ESC risk classification are widely used for early risk stratification of acute pulmonary embolism (PE). The Composite PE Shock (CPES) score has been proposed to better identify normotensive shock. We compared the prognostic performance of PESI, ESC risk class, and CPES. We performed a retrospective chart review of consecutive adults with acute PE managed by PERT (PE Response Team) at three teaching hospitals within the Mount Sinai Health System from January 2020 through June 2024. Multivariable logistic regression was used to predict 30-day mortality. Discrimination was assessed using area under the receiver operating characteristic (AUROC) curves. Net Reclassification Improvement (NRI) and Integrated Discrimination Improvement (IDI) were calculated to assess incremental utility of CPES over PESI and ESC risk class. A total of 404 patients were included (median age: 65 years; 223 [55.2%] women). Median PESI and CPES scores were 82 (IQR: 66–104) and 3 (IQR: 2–4). ESC risk stratification was as follows: low: 12 (3.0%), intermediate low: 71 (17.6%), intermediate high: 235 (58.2%), and high-risk: 86 (21.3%). AUROC for predicting 30-day mortality of PESI, ESC risk class, and CPES were 0.706, 0.643, and 0.420 respectively, and for a two-index model (PESI + ESC), and the full model (PESI + ESC + CPES) were 0.650, and 0.722, respectively. Relative to the two-index model, the full model increased specificity by 10% and decreased sensitivity by 3.7% (NRI: 6.3%, IDI: 1.3%), consistent with modest incremental reclassification. The strongest incremental signal for CPES was observed for receipt of advanced reperfusion therapy, where addition of CPES to PESI and ESC increased AUROC from 0.664 to 0.775. In a contemporary PERT cohort of patients with acute PE, CPES performed poorly as a standalone predictor of 30-day mortality but provided modest conditional incremental information when added to PESI and ESC risk classification. CPES showed a stronger association with receipt of advanced reperfusion therapy, suggesting that it may capture shock physiology relevant to escalation decisions.