Venous lactate improves the prediction of in-hospital adverse outcomes in normotensive pulmonary embolism

Abstract

Background: Arterial lactate is an established risk marker in patients with pulmonary embolism (PE). However, its clinical applicability is limited by the need of an arterial puncture. In contrast, venous lactate can easily be measured from blood samples obtained via routine peripheral venepuncture. Methods: We investigated the prognostic value of venous lactate with regard to in-hospital adverse outcomes and mortality in 419 consecutive PE patients enrolled in a single-center registry between 09/2008 and 09/2017. Results: An optimised venous lactate cut-off value of 3.3 mmol/l predicted both, in-hospital adverse outcome ) and all-cause mortality ). The established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l) had lower prognostic value for adverse outcomes (OR 3.6 [95% CI 1.5-8.7] and 5.7 [95% CI 2.4-13.6], respectively) and did not predict mortality. If added to the 2019 European Society of Cardiology (ESC) algorithm, venous lactate <2.3 mmol/l was associated with a high negative predictive value (0.99 [95% CI 0.97-1.00]) for adverse outcomes in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediatehigh-risk group ). Conclusion: Venous lactate above the upper limit of normal was associated with increased risk for adverse outcomes and an optimised cut-off value of 3.3 mmol/l predicted adverse outcome and mortality. Adding venous lactate to the 2019 ESC algorithm may improve risk stratification. Importantly, the established cut-off value for arterial lactate has limited specificity in venous samples and should not be used.

Prognostic role of elevated lactate in acute pulmonary embolism: A systematic review and meta-analysis

“…Ebner et al discovered that the adjust venous lactate cut-off value can increase the risk of poor in-hospital endpoints in patients with acute PE, while the lactate value exceeding 3.3 mmol/L was a strong predictor of both in-hospital adverse outcome and overall death. 21 Therefore, given the latent risk of arterial puncture, peripheral venous lactate may be a promising form and need further external validated the optimal cut-off value.…”

“…Three of the included studies were prospective, the others were retrospective design. Lactate concentrations were obtained from venous blood sampling in two studies, 20,21 while four studies 13,[17][18][19] evaluated arterial lactate levels. Five studies used 2 mmol/L as a cut-off value, while one study had a venous lactate cut-off value of 3.3 mmol/L.…”

What Is Left for Real-Life Lactate Monitoring? Current Advances in Electrochemical Lactate (Bio)Sensors for Agrifood and Biomedical Applications

“…In the same vein, lactate assessment is highly appreciated in intensive care units (ICUs), where an abnormal level is a beacon of meaningful information of the current and future status of the patient. In this sense, it is possible to relate it with situations such as haemorrhagic shock, pulmonary embolism, cardiogenic shock, respiratory poisoning and renal failure, among others [ 8 , 9 , 10 , 11 , 12 , 13 ]. Moreover, alternative studies pointed out the existence of abnormal lactate concentration in cancer cells during metastases [ 14 ].…”

Assessment of pulmonary embolism severity and the risk of early death

“…Recently, Ebner and colleagues proposed adding the easily obtained venous lactate levels above a higher cutoff, defined as > 3.3 mmol/l, to the 2019 ESC stratification protocol and found that this results in increased sensitivity and specificity in adverse outcome and mortality prediction in the intermediate-high risk subgroup of patients. The proposed higher than previously suggested cutoff may be in part explained by physiologically occurring slight differences in lactate concentrations between venous and arterial blood [45]. Finally, Ebner et al also investigated whether the subgroup of high-risk PE clinically presenting as obstructive shock could be better defined in terms of end-organ perfusion and mortality with lactate measurement, reporting that patients with levels above 3.8 mmol/l were characterized by higher mortality and that applying this improved risk stratification [46].…”