Predictive Value of Wells, Geneva, Bova, and PESI Scores in Elderly Pulmonary Embolism Patients

Introduction

Pulmonary thromboembolism is a critical condition that disproportionately affects the elderly, largely due to the presence of multiple comorbidities and the physiological changes associated with aging. The clinical presentation of pulmonary thromboembolism in geriatric patients often diverges from that seen in younger populations, posing significant challenges in timely diagnosis and treatment. The development of scoring systems designed to predict the severity and prognosis of pulmonary thromboembolism has equipped clinicians with valuable tools for guiding therapeutic decisions and anticipating patient outcomes. However, the applicability and accuracy of these scoring systems within the geriatric population remain questionable, given the distinct characteristics and heightened vulnerability of elderly patients.

The incidence of pulmonary thromboembolism increases with age, making it a significant concern within the geriatric population. Research indicates that the risk of pulmonary thromboembolism doubles with each passing decade after the age of 60 years [1]. This heightened incidence is largely attributable to the higher prevalence of risk factors such as immobilization, cancer, heart failure, and the use of medications like anticoagulants and hormone therapy in older adults. Moreover, the aging process itself induces changes in the coagulation system, resulting in a prothrombotic state [2]. Given these factors, the early identification and management of pulmonary thromboembolism in geriatric patients are essential for improving clinical outcomes.

The clinical presentation of pulmonary thromboembolism in the elderly frequently diverges from the classic symptoms typically observed in younger patients, thereby complicating the diagnostic process. Older adults are more likely to present with nonspecific symptoms, such as dyspnea, syncope, and confusion, rather than the more typical signs of chest pain and hemoptysis [3]. This atypical presentation can contribute to delays in diagnosis, potentially leading to poorer outcomes. Additionally, diagnostic tools such as D-dimer testing and imaging studies can exhibit different sensitivities and specificities in older adults, further complicating the diagnostic process.

When appropriately treated, the mortality rate of pulmonary embolism (PE) can decrease to less than 10% [4]. For clinical suspicion of PE, the Wells and Geneva scores are commonly used, each incorporating different parameters, particularly in relation to pulse values. Consequently, while the Geneva score may yield a more meaningful risk assessment in certain cases, both scores generally provide similar results in predicting clinical outcomes. However, debates continue regarding their accuracy in prognostication [5].

To predict rapid and short-term mortality risks in patients with PE, various risk assessment tools have been developed. One of the most widely used is the Pulmonary Embolism Severity Index (PESI), which is recognized as a validated and reliable scoring system for predicting mortality in patients with PE [6]. PE can lead to secondary right ventricular involvement, resulting in hemodynamic deterioration and potentially fatal outcomes [7]. The relationship between short-term mortality and various clinical markers – such as echocardiography, pulmonary artery blood test, brain natriuretic peptide (BNP), right ventricular dysfunction, myocardial damage, and the levels of troponin T and troponin I – is moderate [6,8]. Moreover, studies have indicated that combining the PESI score with echocardiographic findings enhances the accuracy of mortality prediction in PE patients [9].

Hemodynamic instability is closely associated with the highest mortality rates in PE. The Bova score, which evaluates the relationship between blood pressure and short-term mortality in normotensive patients with PE, is particularly valuable in this context. The Bova score includes 4 parameters: heart rate, systolic blood pressure, troponin levels, and right ventricular dysfunction, making it a robust tool for predicting mortality, especially in normotensive patients [10].

Recent studies have aimed to refine existing scoring systems or create new ones that are more appropriately tailored to the geriatric population. For instance, the Hestia criteria and the Geneva score have been suggested as potential alternatives to the PESI for evaluating the severity of pulmonary thromboembolism in elderly patients. These tools were designed to provide a more nuanced risk assessment by incorporating factors specific to older adults, such as frailty and functional status. Despite these advancements, the evidence supporting the use of these modified or alternative scoring systems in the geriatric population is still in its early stages. Consequently, further research is required to validate their effectiveness and reliability in this demographic.

The management of pulmonary thromboembolism in elderly patients must carefully consider the potential risks associated with treatment, particularly the heightened risk of bleeding that comes with anticoagulation therapy – the cornerstone of pulmonary thromboembolism management. This risk is especially pronounced in older adults who may have renal impairment or a history of falls, making them more susceptible to adverse events [11]. Consequently, the decision to initiate anticoagulation in geriatric patients requires a cautious approach, whereby the benefits of preventing thromboembolic events are meticulously weighed against the risks of bleeding. This delicate balance highlights the critical need for accurate risk stratification tools that can effectively guide treatment decisions in this vulnerable population, ensuring that therapy is both safe and effective.

The assessment of risk and prognostic markers in PE – a condition that ranks prominently among preventable causes of hospital mortality – is crucial for identifying high-risk patients and informing treatment planning. Accurate risk stratification enables clinicians to prioritize interventions, optimize resource allocation, and ultimately improve patient outcomes by ensuring that those at greatest risk receive timely and appropriate care.

The aim of this study is to compare the 30-day mortality and survival outcomes associated with the Wells and Geneva scores, as well as the PESI and Bova scores, in geriatric patients with a diagnosis of PE. This comparison seeks to determine the relative effectiveness of these scoring systems in predicting short-term mortality and survival in an elderly population, thereby contributing to more informed and accurate clinical decision-making.

Material and Methods

ETHICS STATEMENT:

This study was approved by the local ethics committee on December 12, 2019 (approval number: E-19-099). Informed consent was not required due to the retrospective design and use of anonymized data. All procedures complied with the Helsinki Declaration. Due to the nature of the data collection, which involved file review without using identifying information or visuals that could reveal patient identities, obtaining patient consent was deemed unfeasible, and therefore, it was not required.

STUDY DESIGN AND POPULATION:

We conducted a retrospective analysis of hospital records for patients aged ≥65 years who presented to the Emergency Department between May 2019 and December 2019. PE was confirmed by computed tomography pulmonary angiography. A total of 200 patients met the inclusion criteria. Data were accessed and recorded using the hospital’s automation system (HiCamp) and the national health database (e-nabiz). The data were initially recorded by 2 emergency physicians and subsequently verified by an emergency medicine specialist for accuracy.

SCORING SYSTEMS:

Each patient’s Wells score, Geneva score, Bova score, and PESI were calculated as follows: the Wells score is based on clinical features, risk factors, and probability estimates [8]; the Geneva score uses age, heart rate, prior deep vein thrombosis, and other factors [9]; the Bova score incorporates systolic blood pressure <90 mmHg, heart rate ≥100 bpm, troponin elevation, and right ventricular dysfunction [10]; and the PESI assesses 30-day mortality risk by including factors such as age, comorbidities, vital signs, and mental status [11].

DATA COLLECTION:

Demographic information (age, sex), comorbidities (eg, malignancy), mental status changes, and vital signs were obtained from the hospital’s electronic records. Laboratory values included hemogram, biochemistry, arterial blood gas, and coagulation parameters. Echocardiography reports were examined for right ventricular dysfunction.

Blood samples were collected intravenously to determine hemogram, biochemistry, and blood gas values. Hemogram results were obtained using the Advia 2120 device (Siemens, Germany), while biochemical analyses were performed using the Siemens Atellica Solutions device (Siemens, Germany). Blood gas analysis was conducted with the RAPIDLAB1200 Series device (Siemens, Germany), and coagulation tests were performed using the Sysmex CS5100 device (Siemens, Germany). Pulmonary embolism diagnoses were confirmed using the pulmonary artery blood test conducted with the GE Revolution CT scanner (General Electric, USA).

The study population was divided into 2 groups: those who survived and those who died within 30 days. The demographic data, hemogram, biochemistry, blood gas results, echocardiography, and coagulation parameters were analyzed and compared between the 2 groups to identify significant differences or potential predictors of 30-day mortality.

OUTCOMES:

The primary endpoint of this study was to assess the association between scoring values and mortality. Secondary endpoints included evaluating the relationship between hemogram, biochemistry, blood gas parameters, and echocardiographic findings with mortality outcomes.

STATISTICAL ANALYSIS:

All statistical analyses were performed using IBM SPSS Statistics version 29 (IBM Corp, Armonk, NY, USA). Normality was checked using the Shapiro-Wilk test. Continuous variables are reported as mean±standard deviation or median [min–max] and compared using the t test or Mann-Whitney U test, as appropriate. Categorical variables are presented as frequencies and percentages and were compared using thePearson chi-square or Fisher exact test. P<0.05 was considered statistically significant.

Results

A total of 200 patients were included in the study. Table 1 summarizes the demographic characteristics and clinical findings of these patients. The mean age of the cohort was 72.4±6.3 years, and 58% were women. Of the total, 30% (n=60) of patients were identified as having malignancy, and 15% (n=30) presented with altered mental status upon admission.

The study examined the relationships between 30-day mortality (presence/absence) and hospitalization status with the Wells, Bova, Geneva, and PESI scoring systems. A statistically significant association was observed between the presence of malignancy (P<0.05), altered mental status (P<0.05), and mortality. Patients with malignancy demonstrated a hazard ratio (HR) of 2.3 (95% CI: 1.5–3.4), while those with altered mental status exhibited an HR of 3.1 (95% CI: 2.0–4.8).

Table 2 displays the relationship between vital signs and 30-day mortality. No statistically significant correlation was observed (P>0.05) for variables such as systolic blood pressure, heart rate, or oxygen saturation levels. This finding suggests that baseline vital signs, while essential for initial triage, do not independently predict short-term mortality in this cohort.

The relationships between the Wells, Geneva, Bova, and PESI scores and 30-day mortality are presented in Table 3. Among these scoring systems, only the PESI score demonstrated a statistically significant association with mortality (P<0.05). Patients categorized as high risk by the PESI score had a mortality rate of 23%, compared with 6% in the low-risk group.

Table 4 illustrates the relationship between the numerical values of the Wells, Geneva, Bova, and PESI scores and 30-day mortality. The following findings were observed: (1) Bova score: patients with higher scores (≥4) had significantly increased mortality (P<0.001); (2) Geneva score: a moderate but statistically significant relationship was noted (P=0.028); and (3) PESI score: demonstrated the strongest association, with P<0.001.

Multivariate logistic regression analysis confirmed that the PESI score was the most robust predictor of mortality (adjusted odds ratio [OR]: 4.2; 95% CI: 2.8–6.3).

Table 5 presents the relationship between the Wells, Geneva, Bova, and PESI scores and the hospitalization status of patients. Among these systems, only the PESI score demonstrated a statistically significant association with hospitalization outcomes (P<0.05). Patients classified as high-risk by PESI were more likely to require Intensive Care Unit admission (OR: 3.7; 95% CI: 2.2–5.5).

Finally, Table 6 shows the relationship between the numerical values of the Wells, Geneva, Bova, and PESI scores and patients’ hospitalization status. Significant associations with 30-day mortality were observed for the Bova score: P<0.001; Geneva score: P=0.028; and PESI score: P<0.001.

These results emphasize the utility of combining scoring systems, particularly PESI and Bova, for more accurate risk stratification in geriatric patients.

Discussion

LIMITATIONS:

Our retrospective design can introduce selection and information bias, as data quality depended on the completeness of medical records. Additionally, the relatively short timeframe (May–December 2019) restricted the sample size to 200 patients, which can limit generalizability. Finally, the study did not include certain advanced biomarkers or standardized imaging protocols that might further refine risk stratification. Prospective, multicenter research could validate these findings and elucidate the utility of various scoring systems in different geriatric subgroups.

Conclusions

In this retrospective analysis of 200 elderly patients with PE, the PESI score emerged as a robust predictor of short-term mortality when evaluated categorically. However, when using detailed numeric scoring, the Bova, Geneva, and PESI scores all demonstrated significant prognostic value. These results suggest that clinicians should interpret these tools with attention to exact point totals, rather than broad cutoffs alone, to optimize risk stratification and guide targeted interventions for older adults with PE.