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

Abstract

To determine whether troponin I (cTnI) and right ventricular (RV) dysfunction predict adverse in-hospital outcomes in patients admitted to the Emergency Department (ED) with definite nonmassive pulmonary embolism (PE) independent of and in addition to a recently validated clinical prognostic risk score. From a pool of 168 patients with suspected PE, 89 had nonmassive PE confirmed by spiral lung angio-computed tomography. By the clinical prognostic score, in our study sample, 14% had very low risk; 17% had low risk, 20% had intermediate risk, whereas high risk and very high risk were identified in 29 and 20%, respectively. Prevalence of elevated cTnI (>0.1 microg/L, 57%) at admission was comparable among patients grouped by clinical prognostic score (P = NS); echocardiographic RV dysfunction (54%) was more prevalent with intermediate or high clinical risk score (P < 0.02). Increased cTnI predicted primary end-point (development of hemodynamic instability, overall 33 cases, 37%) independent of and in addition to the clinical risk class and RV dysfunction (P < 0.01 for interaction). Fatal events (12 cases, 14%, 5 definite, 7 possible PE-related) were predicted by higher clinical risk score (P < 0.05). In patients with nonmassive central PE admitted to the ED, increased cTnI contributed to identifying those with increased risk of development of hemodynamic instability independent of and in addition to a validated clinically based risk score.

Clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with central and non-massive pulmonary embolism

“…The increase in serum levels of these biochemical markers indicates the occurrence of cardiac damage also in absence of hemodynamic instability at admission to the ED [34,35]. In agreement with literature data [36,37], our study results indicate that right ventricular dysfunction predicts the occurrence of this serious PE-related complication, which significantly conditions the prognosis quoad vitam and quoad valitudinem for PE patients. A large, multinational, randomized trial is currently undergoing to determine whether normotensive patients with right ventricular dysfunction, as detected on an echocardiogram or CT scan, and evidence of myocardial injury, as indicated by a positive troponin test, may benefit from early thrombolytic treatment (ClinicalTrials.gov number, NCT00639743, available at http://clinicaltrials.gov/ct2/ show/NCT00639743?term=NCT00639743&rank=1 accessed on 24 April 2009).…”

The prognostic value of markers of right ventricular dysfunction in pulmonary embolism: a meta-analysis

“…Among those studies, 3 presented both echocardiographic and BNP results, leading to the analysis of 8 studies for echocardiographic markers of RVD ( n = 1,249 patients) [7-14], 3 for CT markers ( n = 503) [15-17], and 7 assessing natriuretic peptides ( n = 582) [8,9,11,18-21]. The follow-up period varied between the in-hospital period and 3 months.…”

“…However, the prognosis impact of these markers remained statistically significant (data not shown). Finally, when common confounding factors were controlled for by a multivariate analysis (performed with the data from five studies [8,10,12-14]), this effect was apparent in only one study [12], thus diminishing the importance of this marker further.…”

Echocardiography does not predict mortality in hemodynamically stable elderly patients with acute pulmonary embolism

“…The cardiologists were blinded to patients' baseline characteristics and treatments. The following six signs of RV dysfunction/pulmonary hypertension were recorded: 1) RV/LV end-diastolic diameter ratio >0.9 in the apical four chamber view, 2) RV hypokinesis (defined as a moderately or severely abnormal motion of RV free wall), 3) paradoxical septal motion, 4) decreased or absent inspiratory collapse of the inferior vena cava, 5) shortened pulmonary acceleration time in the parasternal short axis view (≤100 ms), and 6) increase in RV/right atrial gradient in the apical four chamber or parasternal short axis view (≥30 mm Hg) [10][11][12][13][14]. For the present analysis, we considered only patients who had TTE within three days of PE diagnosis [15].…”