Incremental prognostic value of troponin I and echocardiography in patients with acute pulmonary embolism

Abstract

Background To test the hypothesis that troponin I and echocardiography have an incremental prognostic value in patients with pulmonary embolism (PE). Methods and resultsIn 91 patients with acute PE, echocardiography was performed within 4 h of admission. Troponin I levels were obtained on admission and 12 h thereafter. The 0.06 µg/l troponin I cut-off level was identified as the most useful, high-sensitivity cut-off level for the prediction of adverse outcome by receiver operating characteristic analysis with a sensitivity and specificity of 86%, respectively. Twenty-eight (31%) patients had elevated troponin I levels (4.9±3.8 µg/l). Twenty-one (23%) patients had adverse clinical outcomes including in-hospital death in five, cardiopulmonary resuscitation in four, mechanical ventilation in six, pressors in 14, thrombolysis in 14, catheter fragmentation in three, and surgical embolectomy in three. The area under the receiver operating characteristic curve from multivariate regression models for predicting adverse outcome without troponin I and echocardiography (0.765), with troponin I (0.890) or echocardiography alone (0.858), and the combination of both tests (0.900) was incremental. Three-month survival rate was highest in patients with both a normal troponin I level and a normal echocardiogram (98%). Positive predictive value for adverse clinical outcomes of the combination of echocardiography and troponin I was higher (75% (95%CI 55-88%)) compared with each test alone (echocardiography: 41%, 95% CI 28-56%; troponin I: 64%, 95% CI 46-79%). Conclusions While troponin I measurements added most of the prognostic information for identifying high-risk patients, a normal echocardiogram combined with a negative troponin I level was most useful to identify patients at lowest risk for early death.

Troponin I and right ventricular dysfunction for risk assessment in patients with nonmassive pulmonary embolism in the Emergency Department in combination with clinically based risk score

“…It is worth noting that in our sample, of the patients with normal RV function (n = 41, 46% of the study population), 28% had elevated cTnI. A previous study demonstrates that a normal, rather than an abnormal echocardiographic examination offers the most valuable and additive information for risk stratification in PE [11].…”

“…In our study, RV dysfunction did not predict development of hemodynamic instability independent of elevated cTnI and of the clinical prognostic risk score. The finding may be surprising, given the information available in the 189 -2LL -2Log-Likelihood ratio a All multivariate models were adjusted for a variable indicating the time to optimal anticoagulation from admission literature [10,11] consolidated in a recent meta-analysis [3] on the independent prognostic role of RV dysfunction in PE. We found that RV dysfunction was related to the risk of development of hemodynamic instability in a univariate model, and in a multivariate model including clinical prognostic score but not cTnI (hazard ratio 3.2, 1.1-5.9 vs. development of hemodynamic instability).…”

“…Optimal risk stratification may guide therapeutic management and improve prognosis in nonmassive PE. With this in mind, a recent meta-analysis showed that increased troponins and right ventricular (RV) dysfunction may identify patients with increased risk of fatal and nonfatal PE-related events [3], as demonstrated by a number of previous studies [4][5][6][7][8][9][10][11][12]20]. However, anticoagulation is the only therapeutic option recommended for nonmassive PE [1].…”

Evaluation of right ventricular dysfunction and prediction of clinical outcomes in acute pulmonary embolism by chest computed tomography: comparisons with echocardiography

“…Although echocardiographic criteria for RV dysfunction differ among studies [5,18,19], we evaluated RV hypokinesia as an index of RV dysfunction in accordance with the ICOPER [1].…”

Acute pulmonary embolism: risk stratification in the emergency department

“…The association of elevated troponin and right ventricle dysfunction predicts mortality even in normotensive patients (HR 5.6; 95% CI 1.2-25.9). The incremental prognostic value of right ventricular dysfunction at echocardiography and elevated troponin levels are confirmed in a study in 91 patients with pulmonary embolism [58]. In this study, the ability of predicting in-hospital outcome by troponin and echocardiography, calculated by the area under the receiveroperating characteristic (ROC) curve from multivariate regression models, is incremental: 0.77 without including troponin I and echocardiography, 0.89 with troponin I alone, 0.86 with echocardiography alone, and 0.90 with the combination of troponin and echocardiography.…”