Prognostic significance of multidetector CT in normotensive patients with pulmonary embolism: results of the protect study

Abstract

BackgroundIn patients with acute pulmonary embolism (PE), rapid and accurate risk assessment is paramount in selecting the appropriate treatment strategy. The prognostic value of right ventricular dysfunction (RVD) assessed by multidetector CT (MDCT) in normotensive patients with PE has lacked adequate validation. Methods The study defined MDCT-assessed RVD as a ratio of the RV to the left ventricle short axis diameter greater than 0.9. Outcomes assessed through 30 days after the diagnosis of PE included all-cause mortality and 'complicated course', which consisted of death from any cause, haemodynamic collapse or recurrent PE. Results MDCT detected RVD in 533 (63%) of the 848 enrolled patients. Those with RVD on MDCT more frequently had echocardiographic RVD (31%) than those without RVD on MDCT (9.2%) ( p<0.001). Patients with RVD on MDCT had significantly higher brain natriuretic peptide (269±447 vs 180±457 pg/ml, p<0.001) and troponin (0.10±0.43 vs 0.03±0.24 ng/ml, p=0.001) levels in comparison with those without RVD on MDCT. During follow-up, death occurred in 25 patients with and in 13 patients without RVD on MDCT (4.7% vs 4.3%; p=0.93). Those with and those without RVD on MDCT had a similar frequency of complicated course (3.9% vs 2.3%; p=0.30). Conclusions The PROgnosTic valuE of CT study showed a relationship between RVD assessed by MDCT and other markers of cardiac dysfunction around the time of PE diagnosis, but did not demonstrate an association between MDCT-RVD and prognosis.

Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT

“…Four of the 9 studies were deemed ineligible (22)(23)(24)(25). Hand searching found 5 additional studies (3,13,(29)(30)(31), therefore 10 studies met the eligibility criteria (3,12,13,15,(26)(27)(28)(29)(30)(31) (Figure 1).…”

“…Of the 165 articles screened, 9 appeared potentially eligible and underwent an in depth review (12,15,(22)(23)(24)(25)(26)(27)(28). Four of the 9 studies were deemed ineligible (22)(23)(24)(25).…”

Identification of intermediate-risk patients with acute symptomatic pulmonary embolism

“…For this reason, authors of six studies pooled individual patients' data from their studies that evaluated the prognostic usefulness of imaging and laboratory data in normotensive patients with acute symptomatic PE [5,[8][9][10][11][12]. This study aimed to develop a method to predict PE-related complications based on the clinical presentation and the assessment of RV dysfunction and injury.…”

Derivation of a Screening Tool to Identify Patients with Right Ventricular Dysfunction or Tricuspid Regurgitation after Negative Computerized Tomographic Pulmonary Angiography of the Chest

“…Logistic model fit was assessed by P values from the Pearson's goodness-of-fit χ 2 , the HosmerLemeshow test, the pseudo-R 2 (McFadden), and the area under the ROC curve in the derivation data set (C statistic). 31,32 RESULTS Characteristics of the study population and prevalence of RV dysfunction Patients were enrolled from January 30, 2007, to April 27,2008. Figure 1 shows a flow diagram of patients, starting with subjects screened for inclusion and ending with repeated CTPA instances.…”

“…All CTPA scans were also evaluated for evidence of RV dilation, defined as a ratio of the RV diameter to the left ventricular (LV) diameter greater than 0.9 in transverse plane. 27,28 The IRR radiologist also dichotomously recorded a field designated as "signs of pulmonary hypertension," based on findings of enlarged diameter (RV/LV diameter ratio >0.9) with or without contrast reflux into the vena cava, dilated central pulmonary arteries (e.g., diameter of main pulmonary artery greater than that of ascending aorta), tortuous pulmonary arteries, vascular pruning, and/or a mosaic perfusion pattern, defined as sharply demarcated regions of variable attenuation without evidence of destruction or displacement of pulmonary vessels. 29 All parameters were weighed equally, and radiologists were allowed autonomy to put these findings together in making a dichotomous assessment.…”