Computed Tomography and Echocardiography in Patients With Acute Pulmonary Embolism

George, Elizabeth; Kumamaru, Kanako K.; Ghosh, Nina; Quesada, Carlos Gonzalez; Wake, Nicole; Bedayat, Arash; Dunne, Ruth; Saboo, Sachin S.; Khandelwal, Ashish; Hunsaker, Andetta R.; Rybicki, Frank J.; Gerhard‐Herman, Marie

doi:10.1097/rti.0000000000000048

Cited by 37 publications

(23 citation statements)

References 3 publications

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“…While subjective RV dysfunction has been associated with worse outcomes in PE [31], a number of studies suggest that quantifiers of RV function may better identify high-risk patients, although most of these studies did not test the utility of such parameters in combination with clinical characteristics [11, 13–21]. For example, RV dysfunction, as assessed by tricuspid annular plane systolic excursion (TAPSE) and RV myocardial performance (Tei) index, has been characterized in patients with PE [32, 33].…”

Section: Discussionmentioning

confidence: 99%

Clinical and echocardiographic predictors of mortality in acute pulmonary embolism

Dahhan

Siddiqui

Tapson

et al. 2016

Cardiovasc Ultrasound

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PurposeThe aim of this study was to evaluate the utility of adding quantitative assessments of cardiac function from echocardiography to clinical factors in predicting the outcome of patients with acute pulmonary embolism (PE).MethodsPatients with a diagnosis of acute PE, based on a positive ventilation perfusion scan or computed tomography (CT) chest angiogram, were identified using the Duke University Hospital Database. Of these, 69 had echocardiograms within 24–48 h of the diagnosis that were suitable for offline analysis. Clinical features that were analyzed included age, gender, body mass index, vital signs and comorbidities. Echocardiographic parameters that were analyzed included left ventricular (LV) ejection fraction (EF), regional, free wall and global RV speckle-tracking strain, RV fraction area change (RVFAC), Tricuspid Annular Plane Systolic Excursion (TAPSE), pulmonary artery acceleration time (PAAT) and RV myocardial performance (Tei) index. Univariable and multivariable regression statistical analysis models were used.ResultsOut of 69 patients with acute PE, the median age was 55 and 48 % were female. The median body mass index (BMI) was 27 kg/m2. Twenty-nine percent of the cohort had a history of cancer, with a significant increase in cancer prevalence in non-survivors (57 % vs 29 %, p = 0.02). Clinical parameters including heart rate, respiratory rate, troponin T level, active malignancy, hypertension and COPD were higher among non-survivors when compared to survivors (p ≤ 0.05). Using univariable analysis, NYHA class III symptoms, hypoxemia on presentation, tachycardia, tachypnea, elevation in Troponin T, absence of hypertension, active malignancy and chronic obstructive pulmonary disease (COPD) were increased in non-survivors compared to survivors (p ≤ 0.05). In multivariable models, RV Tei Index, global and free (lateral) wall RVLS were found to be negatively associated with survival probability after adjusting for age, gender and systolic blood pressure (p ≤ 0.05).ConclusionThe addition of echocardiographic assessment of RV function to clinical parameters improved the prediction of outcomes for patients with acute PE. Larger studies are needed to validate these findings.

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Section: Discussionmentioning

confidence: 99%

Clinical and echocardiographic predictors of mortality in acute pulmonary embolism

Dahhan

Siddiqui

Tapson

et al. 2016

Cardiovasc Ultrasound

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“…13 Right ventricular (RV) strain was confirmed by the presence of RV hypokinesia, dilatation, and abnormal interventricular septum movement. 14 In CTPA, a right ventricle/left ventricle (RV/LV) ratio >1 was considered positive for RV strain. Assay of troponin-T (Troponin-T STAT, COBAS 6000-CE, Roche, Indianapolis, IN, USA) was considered positive at ≥0.1 ng/dL.…”

Section: Primary Predictormentioning

confidence: 99%

Association Between Electrocardiographic Findings, Right Heart Strain, and Short‐Term Adverse Clinical Events in Patients With Acute Pulmonary Embolism

Hariharan

Dudzinski

Okechukwu

et al. 2015

Clinical Cardiology

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Background: Electrocardiographic (ECG) changes may be seen with pulmonary emboli (PE). Whether ECG is associated with short-term adverse clinical events after PE is less well established. Hypothesis: ECG findings are associated with short-term clinical deterioration after PE. Methods: Consecutive adult PE patients were enrolled in an academic emergency department from 2008 to 2011. The primary outcome was right heart strain (RHS) on echocardiogram or CT pulmonary angiography, or TnT ≥0.1 ng/mL. We derived an ECG (TwiST) score that is associated with RHS and short-term adverse clinical events. Results: We enrolled 298 patients with PE. On multivariate analysis, T-wave inversion in leads V 1 through V 3 (OR: 4.7, 95% confidence interval [CI]: 1.7-13.2), S wave in lead I (OR: 2.0, 95% CI: 1.1-3.5), and tachycardia (OR: 2.5, 95% CI: 1.3-4.8) were associated with RHS. A TwiST score ≤2 (n = 210, 72%) was 84% (95% CI: 77%-90%) sensitive for the absence of RHS, whereas a TwiST score ≥5 (n = 47, 16%) was 93% (95% CI: 88%-97%) specific for the presence of RHS. Conclusions: A simple ECG (TwiST) score can identify patients likely or not likely to have RHS with >80% specificity and sensitivity and may assist in identifying patients with acute PE at risk for adverse clinical events before pursuing other advanced imaging tests.

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“…In RDV diagnosed by echocardiography, the sensitivity and specificity of right-to-left ventricular ratio (≥1) measured by CTA are 91% (95% CI 72–99%) and 79% (95% CI 69%-87%), respectively [19]. Furthermore, CTA right-to-left ventricular ratio performs as well as echocardiography ratio to predict death after PE [2, 13, 17, 18, 20] and was used interchangeably as inclusion criteria of intermediate-high risk patients in the large PEITHO study [21]. Thus, the American Heart Association, and the European Society of Cardiology guidelines, both recommend using either echocardiography or CTA for risk stratification in PE (a class IIa recommendation with level B evidence) [2, 4].…”

Section: Introductionmentioning

confidence: 99%

Contrast Circulation Time to Assess Right Ventricular Dysfunction in Pulmonary Embolism: A Retrospective Pilot Study

John¹,

Platon

Poletti

et al. 2016

PLoS ONE

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ObjectiveTo optimize enhancement of pulmonary arteries and facilitate diagnosis of pulmonary embolism (PE), modern computed tomography angiography (CTA) contains a contrast bolus tracking system. We explored the diagnostic accuracy of the time-intensity curves given by this automated system to identify right ventricular dysfunction (RVD) in acute PE.Methods114 CTAs with a diagnosis of PE were reviewed. RVD was defined as right-to-left ventricular diameter ratio of 1 or greater. Four parameters on time-intensity curves were identified. Parameters between CTAs with and those without RVD were compared with the Wilcoxon rank-sum test. The ability of the four parameters to discriminate patients with RVD was explored by compiling the area under the operating curves (AUC).ResultsThe time needed by the contrast media to reach the pulmonary artery [8 seconds (IQR: 7–9) versus 7 seconds (IQR: 6–8), p<0.01], the time needed to reach 40 Hounsfield units (HU) [11 seconds (IQR: 8.5–14) versus 9.5 seconds (IQR: 8–10.5), p<0.01], and the contrast intensity reached after 10 seconds [19 HU (IQR: 4–67) versus 53 HU (IQR: 32–80), p<0.05] were all statistically different between CTA with and CTA without RVD. Those three parameters changed gradually across severity categories of RVD (p<0.05 for trend). Their AUC to identify RVD ranged from 0.63 to 0.66. The slope of contrast intensity over time was not informative: [31 HU/s (IQR: 20–57) in CTA with, compared to 36 HU/s (IQR: 22.5–53) in CTA without RVD, p = 0.60].ConclusionSeveral parameters of the time-intensity curve obtained by the bolus tracking system are associated with RVD assessed on CTA images. Of those, the time needed to reach a predefined threshold seems to be the easiest to obtain in any CTA without additional processing time or contrast injection. However, the performance of those parameters is globally low.

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Computed Tomography and Echocardiography in Patients With Acute Pulmonary Embolism

Abstract: Both RV strain on TTE and an increased CT RV/LV diameter ratio are predictors of PE-related 30-day mortality with similar prognostic significance.

Cited by 37 publications

References 3 publications

Clinical and echocardiographic predictors of mortality in acute pulmonary embolism

Clinical and echocardiographic predictors of mortality in acute pulmonary embolism

Association Between Electrocardiographic Findings, Right Heart Strain, and Short‐Term Adverse Clinical Events in Patients With Acute Pulmonary Embolism

Contrast Circulation Time to Assess Right Ventricular Dysfunction in Pulmonary Embolism: A Retrospective Pilot Study

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