A Radiological Nomogram to Predict 30-day Mortality in Patients with Acute Pulmonary Embolism

Published:December 22, 2021DOI:

      Rationale and Objectives

      Acute pulmonary embolism (APE) is a common disease with a high mortality, especially in the short term. Computed tomographic pulmonary angiography (CTPA) is a recommended method in the diagnostic workup for APE; thus, this study aimed to establish a CTPA-based radiological nomogram to predict the 30-day mortality in patients with APE, and to further compare this model with the pulmonary embolism severity index (PESI) and simplified pulmonary embolism severity index (SPESI).

      Materials and Methods

      We retrospectively recruited 158 adults with confirmed APE who underwent CTPA from August 1, 2017, to August 1, 2020. These adults were stratified into two groups according to their 30-day mortality. CTPA-based variables were analyzed using univariate and multivariate analyses, independent risk factors for 30-day mortality were established, and a radiological nomogram was constructed. Subsequently, PESI and SPESI were calculated. The performance of the radiological nomogram model was compared to that of the PESI and SPESI using decision curve analysis and receiver-operating characteristic curve analysis.


      Thirty-three patients died within 30 days (30-day mortality rate, 20.9%). On logistic regression analysis, the right and left ventricular diameter ratio (odds ratio [OR] = 8.709, 95% confidence interval [CI]: 1.085-69.903, p = 0.042), ventricular septal bowing (OR = 8.085, 95% CI: 1.947-33.567, p = 0.004), chronic bronchitis (OR = 4.383, 95% CI: 1.025-18.740, p = 0.046), malignant lung lesions (OR = 17.530, 95% CI: 2.408-127.636, p = 0.005), and pneumonia (OR = 3.477, 95% CI: 1.123-10.766, p = 0.031) were identified as the independent predictors of 30-day mortality. The area under the curve of the radiological nomogram, PESI, and SPESI were 0.900 (95% CI: 0.828-0.971), 0.729 (95% CI: 0.642-0.815), and 0.718 (95% CI: 0.621-0.815), respectively.


      The CTPA-based radiological nomogram appeared valuable for the prediction of 30-day mortality in patients with APE, and was superior to both PESI and SPESI.

      Key Words


      APE (acute pulmonary embolism), CTPA (computed tomographic pulmonary angiography), PESI (pulmonary embolism severity index), SPESI (simplified pulmonary embolism severity index), DCA (decision curve analysis), ROC (receiver-operating characteristic), OR (odds ratio), VTE (venous thromboembolism), RV (right ventricular), LV (left ventricular), RA (right atrium), LA (left atrium), VSB (ventricular septal bowing), MPA (main pulmonary artery), LPA (left pulmonary artery), RPA (right pulmonary artery), AA (ascending aorta), MDCT (multi-detector computed tomographic), RVD (right ventricular dysfunction), COPD (chronic obstructive pulmonary disease), ECHO (Echocardiography)
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        • Heit J.A.
        The epidemiology of venous thromboembolism in the community.
        Arterioscler Thromb Vasc Biol. 2008; 28: 370-372
        • Pulido T.
        • Aranda A.
        • Zevallos M.A.
        • et al.
        Pulmonary embolism as a cause of death in patients with heart disease: an autopsy study.
        Chest. 2006; 129: 1282-1287
        • Aujesky D.
        • Obrosky D.S.
        • Stone R.A.
        • et al.
        Derivation and validation of a prognostic model for pulmonary embolism.
        Am J Respir Crit Care Med. 2005; 172: 1041-1046
        • Jiménez D.
        • Aujesky D.
        • Moores L.
        • et al.
        Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism.
        Arch Intern Med. 2010; 170: 1383-1389
        • Aujesky D.
        • Perrier A.
        • Roy P.M.
        • et al.
        Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism.
        J Intern Med. 2007; 261: 597-604
        • Remy-Jardin M.
        • Pistolesi M.
        • Goodman L.R.
        • et al.
        Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society.
        Radiology. 2007; 245: 315-329
      1. [Chinese guidelines for the diagnosis and treatment of pulmonary hypertension 2018].
        Zhonghua Xin Xue Guan Bing Za Zhi. 2018; 46: 933-964
        • Konstantinides S.V.
        • Meyer G.
        • Becattini C.
        • et al.
        2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC).
        Eur Respir J. 2019; 54
        • Jaff M.R.
        • McMurtry M.S.
        • Archer S.L.
        • et al.
        Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.
        Circulation. 2011; 123: 1788-1830
        • Liu M.
        • Ma Z.H.
        • Guo X.J.
        • et al.
        A septal angle measured on computed tomographic pulmonary angiography can noninvasively estimate pulmonary vascular resistance in patients with chronic thromboembolic pulmonary hypertension.
        J Thorac Imaging. 2012; 27: 325-330
        • Qanadli S.D.
        • El Hajjam M.
        • Vieillard-Baron A.
        • et al.
        New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography.
        AJR Am J Roentgenol. 2001; 176: 1415-1420
        • Mastora I.
        • Remy-Jardin M.
        • Masson P.
        • et al.
        Severity of acute pulmonary embolism: evaluation of a new spiral CT angiographic score in correlation with echocardiographic data.
        Eur Radiol. 2003; 13: 29-35
        • Stein P.D.
        • Henry J.W.
        Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy.
        Chest. 1995; 108: 978-981
        • Heit J.A.
        • Silverstein M.D.
        • Mohr D.N.
        • et al.
        Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study.
        Arch Intern Med. 2000; 160: 809-815
        • Anderson Jr., F.A.
        • Spencer F.A.
        Risk factors for venous thromboembolism.
        Circulation. 2003; 107: I9-16
        • Donzé J.
        • Gal G.Le
        • Fine M.J.
        • et al.
        Prospective validation of the pulmonary embolism severity index. A clinical prognostic model for pulmonary embolism.
        Thromb Haemost. 2008; 100: 943-948
        • Chan C.M.
        • Woods C.
        • Shorr A.F.
        The validation and reproducibility of the pulmonary embolism severity index.
        Journal of Thrombosis and Haemostasis: JTH. 2010; 8: 1509-1514
        • Vanni S.
        • Nazerian P.
        • Pepe G.
        • et al.
        Comparison of two prognostic models for acute pulmonary embolism: clinical vs. right ventricular dysfunction-guided approach.
        Journal of Thrombosis and Haemostasis: JTH. 2011; 9: 1916-1923
        • Righini M.
        • Roy P.M.
        • Meyer G.
        • et al.
        The simplified Pulmonary Embolism Severity Index (PESI): validation of a clinical prognostic model for pulmonary embolism.
        Journal of Thrombosis and Haemostasis: JTH. 2011; 9: 2115-2117
        • Sam A.
        • Sánchez D.
        • Gómez V.
        • et al.
        The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism.
        Eur Respir J. 2011; 37: 762-766
        • Aujesky D.
        • Roy P.M.
        • Verschuren F.
        • et al.
        Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial.
        Lancet (London, England). 2011; 378: 41-48
        • Lankeit M.
        • Jiménez D.
        • Kostrubiec M.
        • et al.
        Predictive value of the high-sensitivity troponin T assay and the simplified Pulmonary Embolism Severity Index in hemodynamically stable patients with acute pulmonary embolism: a prospective validation study.
        Circulation. 2011; 124: 2716-2724
        • Lankeit M.
        • Gómez V.
        • Wagner C.
        • et al.
        A strategy combining imaging and laboratory biomarkers in comparison with a simplified clinical score for risk stratification of patients with acute pulmonary embolism.
        Chest. 2012; 141: 916-922
        • Ghaye B.
        • Szapiro D.
        • Mastora I.
        • et al.
        Peripheral pulmonary arteries: How far in the lung does multi-detector row spiral CT allow analysis?.
        Radiology. 2001; 219: 629-636
        • Patel S.
        • Kazerooni E.A.
        • Cascade P.N.
        Pulmonary embolism: optimization of small pulmonary artery visualization at multi-detector row CT.
        Radiology. 2003; 227: 455-460
        • Sanchez O.
        • Trinquart L.
        • Colombet I.
        • et al.
        Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review.
        Eur Heart J. 2008; 29: 1569-1577
        • Becattini C.
        • Agnelli G.
        • Vedovati M.C.
        • et al.
        Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test.
        Eur Heart J. 2011; 32: 1657-1663
        • Becattini C.
        • Agnelli G.
        • Germini F.
        • et al.
        Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis.
        Eur Respir J. 2014; 43: 1678-1690
        • Choi K.J.
        • Cha S.I.
        • Shin K.M.
        • et al.
        Prognostic implications of computed tomographic right ventricular dilation in patients with acute pulmonary embolism.
        Thromb Res. 2014; 133: 182-186
        • Jiménez D.
        • Kopecna D.
        • Tapson V.
        • et al.
        Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism.
        Am J Respir Crit Care Med. 2014; 189: 718-726
        • Cai B.
        • Bedayat A.
        • George E.
        • et al.
        Malignancy and acute pulmonary embolism: risk stratification including the right to left ventricle diameter ratio in 1596 subjects.
        J Thorac Imaging. 2013; 28: 196-201
        • Kumamaru K.K.
        • George E.
        • Ghosh N.
        • et al.
        Normal ventricular diameter ratio on CT provides adequate assessment for critical right ventricular strain among patients with acute pulmonary embolism.
        Int J Cardiovasc Imaging. 2016; 32: 1153-1161
        • İn E.
        • Aydın A.M.
        • Özdemir C.
        • et al.
        The efficacy of CT for detection of right ventricular dysfunction in acute pulmonary embolism, and comparison with cardiac biomarkers.
        Jpn J Radiol. 2015; 33: 471-478
        • Lyhne M.D.
        • Schultz J.G.
        • MacMahon P.J.
        • et al.
        Septal bowing and pulmonary artery diameter on computed tomography pulmonary angiography are associated with short-term outcomes in patients with acute pulmonary embolism.
        Emerg Radiol. 2019; 26: 623-630
        • Kumamaru K.K.
        • Hunsaker A.R.
        • Bedayat A.
        • et al.
        Subjective assessment of right ventricle enlargement from computed tomography pulmonary angiography images.
        Int J Cardiovasc Imaging. 2012; 28: 965-973
        • Araoz P.A.
        • Gotway M.B.
        • Harrington J.R.
        • et al.
        Pulmonary embolism: prognostic CT findings.
        Radiology. 2007; 242: 889-897
        • Trujillo-Santos J.
        • den Exter P.L.
        • Gómez V.
        • et al.
        Computed tomography-assessed right ventricular dysfunction and risk stratification of patients with acute non-massive pulmonary embolism: systematic review and meta-analysis.
        Journal of Thrombosis and Haemostasis: JTH. 2013; 11: 1823-1832
        • Furlan A.
        • Aghayev A.
        • Chang C.C.
        • et al.
        Short-term mortality in acute pulmonary embolism: clot burden and signs of right heart dysfunction at CT pulmonary angiography.
        Radiology. 2012; 265: 283-293
        • Apfaltrer P.
        • Henzler T.
        • Meyer M.
        • et al.
        Correlation of CT angiographic pulmonary artery obstruction scores with right ventricular dysfunction and clinical outcome in patients with acute pulmonary embolism.
        Eur J Radiol. 2012; 81: 2867-2871
        • Piazza G.
        • Goldhaber S.Z.
        • Kroll A.
        • et al.
        Venous thromboembolism in patients with chronic obstructive pulmonary disease.
        Am J Med. 2012; 125: 1010-1018
        • Park H.
        • Cha S.I.
        • Lim J.K.
        • et al.
        Clinical relevance of chronic respiratory disease in Korean patients with pulmonary thromboembolism.
        J Thorac Dis. 2019; 11: 2410-2419
        • Wang H.
        • Huang Y.
        • Xu C.W.
        • et al.
        Clinical analysis of tumor and non-tumor patients complicated with pulmonary embolism.
        Int J Clin Exp Med. 2015; 8: 18729-18736
        • Lee J.W.
        • Cha S.I.
        • Jung C.Y.
        • et al.
        Clinical course of pulmonary embolism in lung cancer patients.
        Respiration. 2009; 78: 42-48
        • Sun J.M.
        • Kim T.S.
        • Lee J.
        • et al.
        Unsuspected pulmonary emboli in lung cancer patients: the impact on survival and the significance of anticoagulation therapy.
        Lung Cancer. 2010; 69: 330-336
        • Clayton T.C.
        • Gaskin M.
        • Meade T.W.
        Recent respiratory infection and risk of venous thromboembolism: case-control study through a general practice database.
        Int J Epidemiol. 2011; 40: 819-827