One-shot diagnostic and prognostic assessment in intermediate- to high-risk acute pulmonary embolism: The role of multidetector computed tomography

Abstract

Introduction: Contrast-enhanced multidetector computed tomography (MDCT) is useful for the diagnosis of pulmonary embolism (PE). However, current guidelines do not support its use for risk assessment in acute PE patients. Objectives: We compared the prognostic impact of MDCT-derived indices regarding mediumterm mortality in a population of intermediate-to high-risk PE patients, mostly treated by thrombolysis. Methods: Thirty-nine consecutive patients admitted to an intensive care unit with acute PE were studied. All patients had a pulmonary MDCT on admission to the emergency room as part of the diagnostic algorithm. We assessed the following MDCT variables: right ventricular/left ventricular diameter (RV/LV) ratio, arterial obstruction index, pulmonary artery-to-aorta diameter ratio and azygos vein diameter. A 33-month follow-up was performed. Results: Mean age was 59.1±19.6 years, with 80% of patients receiving thrombolysis. Followup all-cause mortality was 12.8%. Of the MDCT-derived variables, only the RV/LV ratio had significant predictive value, being higher in patients who suffered the endpoint (1.6±0.5 vs. 1.9±0.4, p=0.046). Patients with an RV/LV ratio ≥1.8 had 11-fold higher medium-term allcause mortality (3.8% vs. 38.8%, p<0.001). Regarding this endpoint, the c-statistic was 0.78 (95% CI, 0.60---0.96) for RV/LV ratio and calibration was good (goodness-of-fit p=0.594). No other radiological index was predictive of mortality. elsevier.pt, day 19/02/2013. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. 8 R. Baptista et al.Although further studies are needed, the simple-to-calculate RV/LV ratio has good discrimination and calibration for predicting poorer outcomes in patients with acute PE. © 2012 Sociedade Portuguesa de Cardiologia Published by Elsevier España, S.L. All rights reserved. Angiografia pulmonar por tomografia computadorizada em doentes com tromboembolia pumonar de médio a alto risco: avaliação diagnóstica e prognóstica num só exame Resumo Introdução: A angiografia pulmonar por tomografia computadorizada com contraste (angio-TC) é recomendada para o diagnóstico mas não para a estratificação de risco em doentes com tromboembolia pulmonar (TEP). Objectivos: Determinar o impacto prognóstico a médio-prazo de vários índices radiológicos obtidos na angio-TC em doentes com TEP de médio a alto risco, a maioria tratados com fibrinólise. Métodos: Estudaram-se 39 doentes admitidos numa unidade de cuidados intensivos por TEP, todos com angio-TC prévia realizada na urgência e seguiram-se durante 33 meses. Mediram-se as seguintes variáveis: razão entre os diâmetros do ventrículo direito e ventrículo esquerdo (índice VD/VE), índice de obstrução arterial, razão ente os diâmetros da artéria pulmonar e aorta e diâmetro da veia ázigos. Resultados: A idade média foi de 59,1 ± 19,6 anos; 80% dos doentes foram tratados com fibrinólise. Durante o período de seguimento clínico, a mortalidade foi 12,8%. Das variáveis analisadas, apenas o índice VD/...

Prognostic role of embolic burden assessed at computed tomography angiography in patients with acute pulmonary embolism: systematic review and meta‐analysis

“…The OI was reported and calculated according to the Qanadli score in all 22 studies ( Table 2). One study [21] only reported on the scoring system of Mastora, and therefore was excluded; in this study, the OI was not predictive of mortality. In six studies, the prognostic value of an OI below/above predefined cut-off values was evaluated.…”

Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis

“…All but one study reported right-to-left ventricle diameter ratio measured in transverse images [23,27,35,42,44,51]. The analysis of these studies showed a significant association between right-to-left ventricle diameter ratio and death; the OR measured by random effects model was 4.65 (95% CI 1.79-12.07; p50.002) with significant heterogeneity (I 2 51%).…”

Pathophysiology and clinical implications of pulmonary arterial enlargement in COPD

“…The authors found that the right ventricular/left ventricular ratio did have prognostic implications in this population. 72 Heinrich et al compared CT findings, including the pulmonary artery diameter and the PA:A ratio, to preoperative and postoperative hemodynamic measurements in 60 patients undergoing thrombo-endarterectomy. The pulmonary artery diameter was 3.9 ± 0.55 cm and the PA:A ratio was 1.14 ± 0.2.…”