Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism

Abstract

BackgroundIn haemodynamically stable patients with acute symptomatic pulmonary embolism (PE), studies have not evaluated the usefulness of combining the measurement of cardiac troponin, transthoracic echocardiogram (TTE), and lower extremity complete compression ultrasound (CCUS) testing for predicting the risk of PE-related death. Methods The study assessed the ability of three diagnostic tests (cardiac troponin I (cTnI), echocardiogram, and CCUS) to prognosticate the primary outcome of PE-related mortality during 30 days of followup after a diagnosis of PE by objective testing. Results Of 591 normotensive patients diagnosed with PE, the primary outcome occurred in 37 patients (6.3%; 95% CI 4.3% to 8.2%). Patients with right ventricular dysfunction (RVD) by TTE and concomitant deep vein thrombosis (DVT) by CCUS had a PE-related mortality of 19.6%, compared with 17.1% of patients with elevated cTnI and concomitant DVT and 15.2% of patients with elevated cTnI and RVD. The use of any two-test strategy had a higher specificity and positive predictive value compared with the use of any test by itself. A combined three-test strategy did not further improve prognostication. For a subgroup analysis of high-risk patients, according to the pulmonary embolism severity index (classes IV and V), positive predictive values of the two-test strategies for PE-related mortality were 25.0%, 24.4% and 20.7%, respectively. Conclusions In haemodynamically stable patients with acute symptomatic PE, a combination of echocardiography (or troponin testing) and CCUS improved prognostication compared with the use of any test by itself for the identification of those at high risk of PE-related death.

Echocardiography does not predict mortality in hemodynamically stable elderly patients with acute pulmonary embolism

“…Depending on the definition of RV dysfunction, the prevalence of RV dysfunction varied widely and ranged from 36% using a restrictive (RV/LV end-diastolic diameter ratio >0.9 or RV hypokinesis) to 81% using a broader definition (presence of ≥1 echocardiographic sign). Our findings are consistent with results from prior studies in which the prevalence of echocardiographic RV dysfunction varied greatly from 20% to 68% in hemodynamically stable patients with PE [20,21]. This substantial heterogeneity in the prevalence has been attributed to the lack of standardization of criteria used to define RV dysfunction and differences in patient characteristics [22].…”

“…In contrast to the majority of studies enrolling younger hemodynamically stable patients with PE [13,15,20,21,[24][25][26][27][28][29][30], we did not find a relationship between echocardiographic RV dysfunction and short-term clinical outcomes in our sample of elderly patients. In particular, the specific set of echocardiographic criteria recommended by the American Heart Association (presence of RV/LV end-diastolic diameter ratio >0.9 or RV hypokinesis) was not associated with adverse clinical events.…”

Pulmonary embolism: clinical guidelines of European Society of Cardiology (2014).The Task Force of the European Society of Cardiology for diagnosis and management of pulmonary embolism

“…Вследствие этого для улучшения стратификации больных в регистровых и когортных исследованиях изучались различные сочетания клинических дан ных, визуализационных и лабораторных показа телей [222,246,[254][255][256][257][258][259]. Требуется дальнейшее изучение клинического значения большинства этих методов прогноза и шкал, особенно применительно к лечебной тактике.…”

Submassive Pulmonary Embolism: Risk Evaluation and Role of Fibrinolysis

“…The available data, which include the MAPPET-3 and ICOPER registries, prospective studies, and meta-analyses, have related echocardiographic-or computed tomography-determined RVD with a 2-to 2.57-fold excess risk of mortality within 30 days and a high negative predictive value approaching 100 % for ruling out an adverse outcome in normotensive PE patients [10][11][12][13][14]. However, use of RVD alone has been shown to be insufficient for predicting PE-related mortality (positive predictive value of *5-12 %) and the composite of PErelated death or clinical deterioration [12,[14][15][16].…”

“…Results of prospective studies and meta-analyses performed in hemodynamically stable PE patients have correlated troponin I or T elevation with a 2.66-to 21-fold increased risk of PE-related mortality and 4.12-to 24.1-fold excess risk of adverse clinical events [13,14,18,19]. The use of these cardiac biomarkers may be helpful for ruling out (negative predictive value 95.8 %) the development of PE-related death; however, they are unreliable for ruling it in (positive predictive value 10.5 %) [14]. In a multicenter, prospective study by Bova et al, troponin I was not a reliable predictor of the composite of in-hospital PE-related death or clinical deterioration [15].…”