Atrial fibrillation in acute pulmonary embolism: prognostic considerations

The role of electrocardiography (ECG) in prognosticating pulmonary embolism (PE) is increasingly recognized. ECG is quickly interpretable, noninvasive, inexpensive, and available in remote areas.We hypothesized that ECG can provide useful information about PE prognostication. We searched MEDLINE, EMBASE, Google Scholar, Web of Science, abstracts, conference proceedings, and reference lists through February 2017. Eligible studies used ECG to prognosticate for the main outcomes of death and clinical deterioration or escalation of therapy. Two authors independently selected studies; disagreement was resolved by consensus. Ad hoc piloted forms were used to extract data and assess risk of bias. We used a random-effects model to pool relevant data in meta-analysis with odds ratios (ORs) and 95% confidence intervals (CIs); all other data were synthesized qualitatively. Statistical heterogeneity was assessed using the I 2 value. We included 39 studies (9198 patients) in the systematic review. There was agreement in study selection (κ:0.91, 95% CI: 0.86-0.96). Most studies were retrospective; some did not appropriately control for confounders. ECG signs that were good predictors of a negative outcome included S1Q3T3 (OR:3.38, 95% CI: 2.46-4.66, P < 0.001), complete right bundle branch block (OR: 3.90, 95% CI: 2.46-6.20, P < 0.001), T-wave inversion (OR: 1.62, 95% CI: 1.19-2.21, P = 0.002), right axis deviation (OR: 3.24, 95% CI: 1.86-5.64, P < 0.001), and atrial fibrillation (OR: 1.96, 95% CI: 1.45-2.67, P < 0.001) for in-hospital mortality. Several ischemic patterns also were significantly predictive.Our conclusion is that ECG is potentially valuable in prognostication of acute PE.

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“…Twenty studies (4898 patients) reported data on in‐hospital mortality . Several ECG features were meta‐analyzed for this outcome (Table ).…”

Section: Resultsmentioning

confidence: 99%

The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: A systematic review and meta‐analysis

Qaddoura

Digby

Kabali

et al. 2017

Clinical Cardiology

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“…As mentioned in the GRACE score and other clinical rules (LR-PED), atrial fibrillation may be an independent predictor of 6-month mortality in patients with acute pulmonary embolism; however, these data should be tested and validated in prospective studies using larger cohorts (28, 29). In our study, although the prevalence of atrial fibrillation was 37.9%, the difference between the survivor and non-survivor groups was not statistically significant.…”

Section: Discussionmentioning

confidence: 99%

Chronic kidney disease: Prognostic marker of nonfatal pulmonary thromboembolism

Ouatu¹,

Floria²,

Ionescu³

et al. 2015

Anatol J Cardiol

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Objective:Renal dysfunction is associated with increased cardiovascular morbidity and mortality. The alteration in renal function as a marker of mortality in pulmonary thromboembolism (PTE) has not been studied extensively.Methods:Four hundred four consecutive patients diagnosed with non-high-risk PTE (without cardiogenic shock or blood pressure <90 mm Hg) were prospectively enrolled in the study between 2005-2010. Kidney function, based on glomerular filtration rate (GFR), calculated by the simplified modification in diet in renal disease (MDRD) equation (sMDRD); troponin I; B-type natriuretic peptide (BNP); and echocardiographic markers of right ventricular (RV) function were determined in survivors versus non-survivors after a 2-year follow-up.Results:GFR was significantly lower in non-survivors than in survivors: 51.85±19.08 mL/min/1.73 m2 and 71.65±23.21 mL/min/1.73 m2, respectively (p=0.000). The highest 2-year mortality rate (20%) was recorded in patients with moderate renal dysfunction associated with RV dysfunction. Using multivariate analysis, we found that GFR is an independent predictor of 2-year mortality (OR 0.973, 95% CI: 0.959-0.987, p=0.000), besides troponin I, dyslipidemia, acceleration time of pulmonary ejection, pericardial effusion, and BNPConclusion:The association of renal dysfunction with right ventricular dysfunction in patients with non-fatal pulmonary thromboembolism resulted in high mortality. Renal dysfunction, assessed by glomerular filtration rate, may be used in the risk stratification of patients with non-high-risk pulmonary thromboembolism, besides troponin I, BNP and right ventricle echocardiographic dysfunction markers.

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“…The reported prevalence of atrial fibrillation in acute pulmonary embolism (PE) varies widely, and most studies are focused on diagnostic purposes . Moreover, as the temporal sequence of events has not been determined in these studies, the question of cause and effect remains unanswered.…”

Section: Introductionmentioning

confidence: 99%

Venous Thromboembolism Increases the Risk of Atrial Fibrillation: The Tromsø Study

Hald

Enga

Løchen

et al. 2014

JAHA

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BackgroundPulmonary embolism (PE) may trigger atrial fibrillation through increased right atrial pressure and subsequent atrial strain, but the degree of evidence is low. In this study, we wanted to investigate the impact of incident venous thromboembolism (VTE) on future risk of atrial fibrillation in a prospective population‐based study.Methods and ResultsThe study included 29 974 subjects recruited from the Tromsø study (1994–1995, 2001–2002, 2007–2008). Incident VTE and atrial fibrillation events were registered from date of enrolment to end of follow‐up, December 31, 2010. Cox proportional hazard regression models using age as time‐scale and VTE as a time‐dependent variable were used to estimate crude and multivariable hazard ratios (HRs) for atrial fibrillation with 95% confidence intervals (CIs). During 16 years of follow up, 540 (1.8%) subjects had an incident VTE event, and 1662 (5.54%) were diagnosed with atrial fibrillation. Among those with VTE, 50 (9.3%) developed subsequent atrial fibrillation. Patients with VTE had 63% higher risk of atrial fibrillation compared to subjects without VTE (multivariable‐adjusted HR: 1.63, 95% CI: 1.22 to 2.17). The risk of atrial fibrillation was particularly high during the first 6 months after the VTE event (HR 4.00, 95% CI: 2.21 to 7.25) and among those with PE (HR 1.78, 95% CI: 1.13 to 2.80).ConclusionsWe found that incident VTE was associated with future risk of atrial fibrillation. Our findings support the hypothesis that PE may lead to cardiac dysfunctions that, in turn, could trigger atrial fibrillation.

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Atrial fibrillation in acute pulmonary embolism: prognostic considerations

Abstract: The presence of AF, irrespective of its timing, may independently predict mortality in patients with acute PE. These data should be tested and validated in prospective studies using larger cohorts.

Cited by 40 publications

References 24 publications

The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: A systematic review and meta‐analysis

The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: A systematic review and meta‐analysis

Chronic kidney disease: Prognostic marker of nonfatal pulmonary thromboembolism

Venous Thromboembolism Increases the Risk of Atrial Fibrillation: The Tromsø Study

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