Prognostic Value of Emergency Physician Performed Echocardiography in Patients with Acute Pulmonary Thromboembolism

Abstract

Introduction:Pulmonary embolism (PE) is a life-threatening illness with high morbidity and mortality. Echocardiography (ECG) plays an important role in the early identification of right ventricular (RV) dysfunction, making it a helpful tool in identifying hemodynamically stable patients affected by PE with a higher mortality risk. The purpose of this study was to evaluate if one or more ECG indexes could predict a short-term evolution towards RV dysfunction.Methods:We selected all patients consecutively admitted to the Careggi Hospital Emergency Department with the clinical suspicion of PE, confirmed by computed tomography angiography prior to enrollment. Subsequently, properly trained emergency physicians acquired a complete ECG to measure RV morphological and functional indices. For each patient, we recorded if he or she received a fibrinolytic treatment, a surgical embolectomy or heparin therapy during the emergency department (ED) stay. Then, every patient was re-evaluated with ECG, by the same physician, after 1 week in our intensive observation unit and 1 month as outpatient in our ED regional referral center for PE.Results:From 2002 to 2007, 120 consecutive patients affected by PE were evaluated by echocardiography at the Careggi Hospital ED. Nine patients (8%) were treated with thrombolytic therapy. Six died within 1 week and 4 abandoned the study, while the remaining 110 survived and were re-evaluated by ECG after 1 week and 1 month. The majority of the echocardiographic RV indexes improve mostly in the first 7 days: Acceleration Time (AT) from 78±14 ms to 117±14 ms (p<0.001), Diameter of Inferior Vena Cava (DIVC) from 25±6 mm to 19±5 mm (p<0.001), Tricuspid Annular Plane Systolic Excursion (TAPSE) from 16±6 mm to 20±6 mm (p<0.001). Pulmonary Artery Systolic Pressure (PASP) showed a remarkable decrease from 59±26 mmHg to 37±9 mmHg, (p<0.001). The measurements of the transverse diameters of both ventricles and the respective ratio showed a progressive normalization with a reduction of RV diameter, an increase of Left Ventricular (LV) diameter and a decrease of RV/LV ratio over time. To evaluate the RV function, the study population was divided into 3 groups based on the TAPSE and PASP mean values at the admission: Group 1 (68 patients) (TAPSE+/ PASP−), Group 2 (12 patients) (TAPSE−/PASP−), and Group 3 (30 patients) (TAPSE−/PASP+). Greater values of AT, minor RV diameter, greater LV diameter and a lesser RV/LV ratio were associated with a short-term improvement of TAPSE in the Group 2. Instead, in Group 3 the only parameter associated with short-term improvement of TAPSE and PASP was the treatment with thrombolytic therapy (p<0.0001).Conclusion:Greater values of AT, minor RV diameter, greater LV diameter and a lesser RV/LV ratio were associated with a short-term improvement of TAPSE−/PASP− values. Patients with evidence of RV dysfunction (TAPSE−/PASP+), may benefit from thrombolytic therapy to improve a short- term RV function. After 1 month, also a decreased DIVC predicted improved RV function.

Echocardiography in the Risk Assessment of Acute Pulmonary Embolism

“…29 This was confirmed in another study, where reduction of the diameter of the IVC was noted in the first 7 days of a cohort of 120 patients with clinically significant acute PE who received treatment. 31…”

The “5Es” of Emergency Physician–performed Focused Cardiac Ultrasound: A Protocol for Rapid Identification of Effusion, Ejection, Equality, Exit, and Entrance

“…41 TAPSE is a technique for assessing RV function that is well described in the cardiology literature, but to our knowledge only described once in the EP literature. [42][43][44][45] In our experience it is easily measured when an adequate A4C view is present and has been described as reproducible and perhaps better than RV size as a predictor of PE severity. 41,43,45 Right ventricle systolic pressure may be estimated quantitatively when tricuspid regurgitation is present.…”

Expanding our FoCUS: the utility of advanced echocardiography in the emergency department

“…Multiple studies have assessed the optimal management for patients with submassive PE, yet uncertainty remains. In a normotensive patient with sub‐massive PE confirmed on CTPA, the use of advanced echo to evaluate the Tricuspid Annular Plane Systolic Excursion (TAPSE) allows prognostication of clinical course and can influence the difficult decision regarding use of thrombolysis . In addition, a finding of clot‐in‐transit is associated with increased mortality, and endovascular techniques or thrombolysis should be carefully considered in a normotensive patient with this finding.…”