Cardiac biomarkers and clinical scores for risk stratification in elderly patients with non-high-risk pulmonary embolism

Performance of the Simplified Pulmonary Embolism Severity Index in predicting 30-day mortality after acute pulmonary embolism: Validation from a large-scale cohort

BACKGROUND

The performance of existing prognostic scores including the simplified Pulmonary Embolism Severity Index (sPESI) for short-term mortality of non-high-risk PE in Chinese population has not been widely validated.

METHODS

Non-high-risk patients were included from the prospective cohort of the China pUlmonary Thromboembolism REgistry Study (CURES). The sPESI, RIETE, Geneva, modified FAST, and Bova score were validated. The discriminatory performance was measured by the area under the curve (AUC). We also compared the sensitivity, odds ratio, specificity, positive predictive value and negative predictive value of these scores.

RESULTS

A total of 6,873 non-high-risk patients with acute PE were included and 241 (3.5 %) patients died within 30 days. Compared to the Geneva, modified FAST, and Bova score, the AUCs for predicting 30-day death of sPESI and RIETE score were higher at 0.712 (95 % CI, 0.680, 0.743) and 0.723 (95 % CI, 0.691, 0.755) respectively. The sPESI demonstrated the highest sensitivity at 0.809, while the RIETE score, Geneva, Modified FAST and BOVA score showed sensitivities of 0.622, 0.568, 0.477 and 0.502 respectively. A sPESI ⩾1 point was associated with a 4.7-fold increased risk of 30-day all-cause mortality (95 % CI, 3.427, 6.563, p < 0.001), while a RIETE score of ⩾1 point was associated with a 4.5-fold increased risk (95 % CI, 3.127, 6.341, p < 0.001). The Geneva score, modified FAST and Bova score showed inferior performance.

CONCLUSIONS

The implementation of the fewer-parameter, easier-to-calculate sPESI in Chinese patients with PE can help to discriminate patients with extremely low risk of short-term mortality for home treatment or early discharge.

Role of serum biomarkers in predicting management strategies for acute pulmonary embolism

Background

Acute pulmonary embolism (APE) is a condition that can be fatal. The severity of the disease influences therapeutic decisions, and mortality varies significantly depending on the condition's severity. Identification of patients with a high mortality risk is crucial. Since inflammation, hemostatic, and coagulation abnormalities are linked to APE, serum biomarkers may be helpful for prognostication.

Aim

To evaluate the significance of serum biomarkers in APE risk assessment and the suitability of these biomarkers for management and decision-making.

Methods

This study involved 60 adult patients with APE who were divided according to risk categorization. It was conducted in Chest, Cardiology and Internal Medicine department, Zagazig University Hospitals from December 2022 to May 2023. Several hematological biomarkers and their significance in APE risk assessment were measured with a comparison with the latest risk stratification methods which include haemodynamic measures and right ventricular (RV) dysfunction echocardiographic markers.

Results

Each risk group involved 20 patients (high, intermediate (10 were intermediate-high and 10 were intermediate-low) and low risk group). They were 34 females and 26 males with the mean ± SD of their age was 59.25 ± 13.06 years. Regarding hematological biomarkers, there were statistically significant differences as regards; lymphocytes, platelet to lymphocyte ratio (PLR), albumin, blood urea nitrogen (BUN), C-reactive protein (CRP) and D-dimer with highly statistically significant differences as regards; neutrophil to lymphocyte ratio (NLR), BUN to albumin (B/A) ratio, troponin I (TnI), and brain natriuretic peptide (BNP). TnI had the highest specificity and predictive value positive (PVP) and BNP had the highest sensitivity and predictive value negative (PVN) in predicting high risk groups. The Lymphocyte and NLR showed the lowest sensitivity and the albumin and B/A ratio had the lowest specificity. Regarding transthoracic echocardiography (TEE); there was a statistically significant increase regarding pulmonary artery systolic pressure (PASP) and a highly statistically significant increase regarding the right ventricle/left ventricle (RV/LV) ratio. There were statistically significant decreases regarding tricuspid annular plane systolic excursion (TAPSE) and peak systolic velocity of tricuspid annulus (S') among risk groups.

Conclusion

APE prognosis can be judged accurately by simultaneously measuring a few biomarkers along with haemodynamic variables and echocardiographic parameters of RV dysfunction.

Prognosis of patients with acute pulmonary embolism and discordant right ventricle strain serum biomarkers

BACKGROUND

Right ventricle strain serum biomarkers, such as high-sensitivity cardiac troponin T (hs-cTnT) and NT-pro-brain natriuretic peptide (NT-proBNP), are prognostic in patients with pulmonary embolism (PE). Prognosis accuracy in patients with discordancy between serum biomarkers remains, however, unknown.

METHODS

We performed a retrospective analysis in patients with intermediate or high risk PE and discordant serum biomarkers of RV strain as follows: high hs-cTnT and low NT-proBNP ('high troponin discordance'), compared to patients with low hs-cTnT and high NT-proBNP ('high NT-proBNP discordance'). Cut-off values for high hs-cTnT were ≥14 pg/mL in patients <75 years and ≥45 pg/mL in patients >75-year. Cut-off values for high NT-proBNP were ≥600 pg/mL. The primary end-point was a composite of death, resuscitated cardiac arrest, mechanical ventilation, and inotrope use at one month. 'High troponin discordance', age, sex and body mass index (BMI) were included in a logistic regression model. Time to event analysis was performed using Kaplan Meier curves and Log-rank test.

RESULTS

73 patients were included. 'High troponin discordance' patients (n=41) were younger, presented with a higher heart rate, more frequent bilateral PE, and received more thrombolytics as treatment compared with 'high NT-proBNP discordance' patients (n = 32). Primary end-point was significantly higher in the 'high troponin discordance' patients (29.3% vs 9.4%, p=0.045). 'High troponin discordance' was independently associated with the primary end-point after adjusting for age, sex and BMI. Log rank test confirmed worse outcome in the high troponin discordance group (p=0.037).

CONCLUSIONS

High troponin discordance' patients with intermediate/high risk PE, had worse outcomes than patients with high BNP discordance.

Fibulins: a new biomarker for pulmonary thromboembolism?

OBJECTIVES

Fibulin-1, -2, -4, and -5 have important role in several vascular diseases. We aimed to investigate if fibulin-4 and -5 can be used as a biomarker for pulmonary thromboembolism (PTE).

METHODS

This is a prospective case control study. Thirthy patients diagnosed with PTE and 31 in the control group. Data on demographic characteristics, length of hospital stay, blood cell counts, troponin and BNP levels, arterial blood gases, radiological reports, indication for thromboembolitic treatment, intensive care unit (ICU) requirement, and loss of life were recorded for the patients group. Serum Fibulin-4 and Fibulin-5 levels were measured.

RESULTS

Fibulin 4 levels correlated positively with female gender (p < .01, r = 0.433). Positive results were found in 14 (46.7%) patients for PESI.0.1; in 7 (23.3%) patients for D-dimer; in 7 (23.3%) patients for troponin-I; in 7(23.3%) patients for BNP. Median values for Fibulin 4 level were significantly higher in patients positive for BNP. Fibulin-5 level was found to be correlated with the presence of embolism (p = .041, r = 0.263).

CONCLUSIONS

Fibulin-4 and -5 have been shown to be relevant to cardiovascular biology and diseases. Experimental studies and observations in humans show that they may play a role in several cardiovascular diseases particularly pulmonary embolism.

Applying rigorous eligibility criteria to studies evaluating prognostic utility of serum biomarkers in pulmonary embolism: A systematic review and meta-analysis

PURPOSE

To evaluate the value of biomarkers to prognosticate outcomes in patients with pulmonary embolism among studies of sound methodical quality.

METHODS

Ovid MEDLINE, Embase, CENTRAL, and non-indexed citations were searched from inception to March 2019. Biomarkers of interest included troponin I (TnI), troponin T (TnT), high-sensitive TnT (HS-TnT), brain natriuretic peptide (BNP), N-terminal pro-BNP (NT-proBNP), heart fatty acid binding protein (H-FABP), and D-dimer (DD). Included studies utilized key features of the Reporting Recommendations for Tumour Marker Prognostic Studies (REMARK) checklist and satisfied requirements of the Quality in Prognosis Studies (QUIPS) tool. The primary outcome was 30-day all-cause mortality (ACM). Secondary outcomes included PE-related mortality, or complicated clinical course (CCC). Pooled relative risk ratios (RR) were calculated using inverse-variance-weighted random-effects method.

RESULTS

Seventeen studies were analyzed. TnT ≥ 0.1 ng/mL and HS-TnT ≥ 14 pg/mL were associated with an increased 30-day ACM with RRs of 6.24 (95% CI, 1.86-20.96, I2 = 35%) and 6.81 (95% CI, 2.46-18.88, I2 = 0%), respectively. In the short-term (≤30 days): (1) TnI can prognosticate PE-related mortality; (2) both TnT and HS-TnT can prognosticate a CCC; (3) H-FABP can prognosticate a CCC; and (4) NT-proBNP can prognosticate a CCC. In the long-term (>30 days): (1) HS-TnT can prognosticate ACM; and (2) NT-proBNP can prognosticate ACM and PE-related mortality.

CONCLUSIONS

Several methodically sound studies allow for data pooling, and suggest that TnT, HS-TnT, TnI, NT-proBNP and H-FABP have prognostic value in patients with PE but confidence intervals are wide and relatively few patients constitute the analyses. The value of such markers on influencing clinical management remains to be determined.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019129889.

High-sensitive cardiac troponin T as a marker of hemorrhagic complications in elderly patients anticoagulated for non-massive pulmonary embolism

BACKGROUND

Recent data have raised concerns about the risk/benefit ratio of thrombolysis in non-high risk pulmonary embolism patients due to increased serious bleeding events. Whether cardiac biomarkers could be of help for bleeding risk stratification in this setting remains elusive.

OBJECTIVES

To determine the prognostic accuracy of hs-cTnT, NT-proBNP, RIETE and PESI score for the occurrence of clinically relevant bleeding (CRB) in elderly patients under conventional anticoagulation therapy for non-massive pulmonary embolism (NMPE).

METHODS

We evaluated 230 elderly patients with available blood sample taken within one day from diagnosis. The primary study endpoint was CRB at 1, 3 and 24 months. Prognostic accuracies and associations were determined using C-statistics and subhazard ratios (SHR), respectively.

RESULTS

hs-cTnT displayed the highest discriminatory power at 1 month (C-statistics: 0.77, 95% CI: 0.68-0.88) which remained stable over time. Although C-statistics comparison indicated that hs-cTnT was not statistically superior to RIETE score (0.77 vs 0.67, p = 0.11), adding hs-cTnT to RIETE score significantly improved the C-statistics from 0.67 to 0.78 (p = 0.02). SHRs indicated that for each hs-cTnT log-unit increase, there was a 58% increase in the risk of CRB independently of the RIETE score (adjusted SHR: 1.58, 95% CI: 1.31-1.92). At the pre-specified cut-off of 14 ng/l, the negative predictive value of hs-cTnT was 96.9% (95% CI: 91.4-99.0) and 94.9 (95%CI: 88.6-97.8) at 1 and 3 months, respectively.

CONCLUSION

In elderly, hs-cTnT provides incremental prognostic information over the RIETE score and could represent a valuable tool to identify NMPE patients at low risk of bleeding.

Risk stratification of elderly patients with acute pulmonary embolism

BACKGROUND

Combining high-sensitivity cardiac Troponin T (hs-cTnT), NT-pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hs-CRP) may improve risk stratification of patients with pulmonary embolism (PE) beyond the PESI risk score.

METHODS

In the prospective multicentre SWITCO65+ study, we analysed 214 patients ≥ 65 years with a new submassive PE. Biomarkers and clinical information for the PESI risk score were ascertained within 1 day after diagnosis. Associations of hs-TnT, NT-proBNP, hs-CRP and the PESI risk score with the primary endpoint defined as 6-month mortality were assessed. The discriminative power of the PESI risk score and its combination with hs-cTnT, NT-proBNP and hs-CRP for 6-month mortality was compared using integrated discrimination improvement (IDI) index and net reclassification improvement (NRI).

RESULTS

Compared with the lowest quartile, patients in the highest quartile had a higher risk of death during the first 6 months for hs-cTnT (adjusted HR 10.22; 95% CI 1.79-58.34; P = 0.009) and a trend for NT-proBNP (adjusted HR 4.3; 95% CI 0.9-20.41; P = 0.067) unlike hs-CRP (adjusted HR 1.97; 95% CI 0.48-8.05; P = 0.344). The PESI risk score (c-statistic 0.77 (95% CI 0.69-0.84) had the highest prognostic accuracy for 6-month mortality, outperforming hs-cTnT, NT-proBNP and hs-CRP (c-statistics of 0.72, 0.72, and 0.54), respectively. Combining all three biomarkers had no clinically relevant impact on risk stratification when added to the PESI risk score (IDI = 0.067; 95% CI 0.012-0.123; P = 0.018; NRI = 0.101 95% CI -0.099-0.302; P = 0.321).

CONCLUSIONS

In elderly patients with PE, 6-month mortality can adequately be predicted by the PESI risk score alone.

Cardiac Troponins in Low-Risk Pulmonary Embolism Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with low-risk pulmonary embolism (PE) should be considered as per current scoring systems for ambulatory treatment. However, there is uncertainty whether patients with low scores and positive troponins should require hospitalization.

METHODS

We searched MEDLINE, SCOPUS, and Cochrane Library databases from inception to December 2016 and collected longitudinal studies that evaluated the prognostic value of troponins in patients with low-risk PE. The primary outcome measure was 30-day all-cause mortality. We calculated odds ratio (OR), likelihood ratios (LRs), and 95% confidence intervals (CI) by using randomeffects models.

RESULTS

The literature search identified 117 candidate articles, of which 16 met the criteria for review. Based on pulmonary embolism severity index (PESI) or simplified PESI score, 1.2% was the all-cause mortality rate across 2,662 participants identified as low-risk. A positive troponin status in patients with low-risk PE was associated with an increased risk of 30-day all-cause mortality (odds ratio [OR]: 4.79; 95% confidence interval [CI]: 1.11 to 20.68). The pooled likelihood ratios (LRs) for all-cause mortality were positive LR 2.04 (95% CI, 1.53 to 2.72) and negative LR 0.072 (95% CI, 0.37 to 1.40).

CONCLUSIONS

The use of positive troponin status as a predictor of increased mortality in low-risk PE patients exhibited relatively poor performance given the crossed negative LR CI (1.0) and modest positive LR. Larger prospective trials must be conducted to elucidate if patients with low-risk PE and positive troponin status can avoid hospitalization.

Circulating extracellular DNA is an independent predictor of mortality in elderly patients with venous thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in elderly patients. Extracellular DNA is a pro-inflammatory and pro-thrombotic mediator in vitro and in animal models. Levels of circulating extracellular DNA (ceDNA) are increased in VTE patients, but the association of ceDNA with VTE extent and clinical outcome is poorly understood.

OBJECTIVES

We analyzed the association of ceDNA with the extent of VTE, categorized as distal and proximal deep vein thrombosis and pulmonary embolism, and with the clinical outcomes VTE recurrence and mortality.

METHODS

We quantified ceDNA by a fluorescent probe, as well as circulating nucleosomes and neutrophil extracellular traps (NETs) by ELISA in plasma from 611 patients aged ≥ 65 years with acute VTE of a prospective cohort study (SWITCO65+).

RESULTS

Levels of ceDNA and nucleosomes, but not NETs, correlated with VTE extent. Infectious comorbidities independently increased ceDNA levels in VTE. CeDNA strongly correlated with C-reactive protein and leukocytosis, suggesting an association of ceDNA with inflammation in VTE patients. CeDNA furthermore predicted PE-related and all-cause mortality, but not VTE recurrence, during a 3-year follow-up.

CONCLUSIONS

Our study suggests that ceDNA levels in VTE patients reflect the degree of inflammation and may serve as a biomarker to stratify VTE patients at risk for mortality.

Pulmonary embolism severity assessment and prognostication

For patients who have acute symptomatic pulmonary embolism (PE), risk of short-term death and adverse outcomes should drive the initial treatment decisions. Practice guidelines recommend that patients who have a high-risk of PE-related death and adverse outcomes, determined by the presence of haemodynamic instability (i.e., shock or hypotension), should receive systemically administered thrombolytic therapy. Intermediate-high risk patients might benefit from close observation, and some should undergo escalation of therapy beyond standard anticoagulation, particularly if haemodynamic deterioration occurs. Low-risk for adverse outcomes should lead to early hospital discharge or full treatment at home. Validated prognostic tools (i.e., clinical prognostic scoring systems, imaging studies, and cardiac laboratory biomarkers) assist with risk classification of patients who have acute symptomatic PE.

Biomarkers for Clinical Decision-Making in the Management of Pulmonary Embolism

BACKGROUND

Pulmonary embolism (PE) is associated with high all-cause and PE-related mortality and requires individualized management. After confirmation of PE, a refined risk stratification is particularly warranted among normotensive patients. Previous prognostic models favored combinations of echocardiography or computed tomography suggestive of right ventricular (RV) dysfunction together with biomarkers of RV dysfunction (natriuretic peptides) or myocardial injury (cardiac troponins) to identify candidates for thrombolysis or embolectomy. In contrast, current predictive models using clinical scores such as the Pulmonary Embolism Severity Index (PESI) or its simplified version (sPESI) rather seek to identify patients, not only those at higher risk requiring observation for early detection of hemodynamic decompensation, and the need for initiation of rescue reperfusion therapy, but also those at low risk qualifying for early discharge and outpatient treatment. Almost all prediction models advocate the additional measurement of biomarkers along with imaging of RV dysfunction as part of a comprehensive algorithm.

CONTENT

The following mini-review will provide an updated overview on the individual components of different algorithms with a particular focus on guideline-recommended and new, less-established biomarkers for risk stratification, and how biomarkers should be implemented and interpreted.

SUMMARY

Ideally, biomarkers should be part of a comprehensive risk stratification algorithm used together with clinical risk scores as a basis, and/or imaging. For this purpose, cardiac troponins, including high-sensitivity troponin generations, natriuretic peptides, and h-FABP (heart-type fatty acid–binding protein) are currently recommended in guidelines. There is emerging evidence for several novel biomarkers that require further validation before being applied in clinical practice.

Troponin I and D-Dimer for Discriminating Acute Pulmonary Thromboembolism from Myocardial Infarction

BACKGROUND

Acute pulmonary thromboembolism (APTE) is a life-threatening condition, often manifesting with chest pain, dyspnea, and increased cardiac biomarkers including cardiac troponin I (CTI) and D-dimer. Therefore, APTE is often misdiagnosed with classical non-ST elevation myocardial infarction (NSTEMI), resulting in unnecessary coronary interventions and a delay of therapy.

OBJECTIVES

Our aim was to distinguish APTE from NSTEMI based on CTI and D-dimer levels.

METHODS

Complete clinical and laboratory data sets from APTE patients (n = 123) were compared with matched NSTEMI patients (n = 123) who presented with chest pain. The APTE diagnosis was confirmed by chest tomography, angiography, or radionuclide ventilation-perfusion scan, while NSTEMI was established by clinical symptoms, cardiac biomarkers, and coronary angiography. Clinical characteristics, CTI (initial and peak), and D-dimer levels at presentation were retrospectively analyzed.

RESULTS

The clinical characteristics were not different between APTE and NSTEMI patients. However, significantly lower initial CTI (0.2 ± 0.5 vs. 4.4 ± 9.5 ng/ml) and peak CTI (0.7 ± 2.7 vs. 17.1 ± 20.4 ng/ml), but higher initial D-dimer (9.8 ± 9.4 vs. 1.6 ± 3.6 ng/ml), distinguished APTE from NSTEMI. By receiver operating characteristic curve analysis, the cutoff values for initial CTI, peak CTI, and D-dimer were 0.25, 0.98, and 3.18 ng/ml, respectively.

CONCLUSION

Patients with APTE exhibited lower initial and peak CTI but higher D-dimer levels than NSTEMI patients. Assessing cardiac biomarkers is useful for differentiating APTE from NSTEMI. Further large randomized biomarker studies are urgently needed to facilitate a better APTE diagnosis since clinical characteristics are not particularly helpful.

Guidance for the treatment of deep vein thrombosis and pulmonary embolism

This guidance document focuses on the diagnosis and treatment of venous thromboembolism (VTE). Efficient, cost effective diagnosis of VTE is facilitated by combining medical history and physical examination with pre-test probability models, D dimer testing and selective use of confirmatory imaging. Clinical prediction rules, biomarkers and imaging can be used to tailor therapy to disease severity. Anticoagulation options for acute VTE include unfractionated heparin, low molecular weight heparin, fondaparinux and the direct oral anticoagulants (DOACs). DOACs are as effective as conventional therapy with LMWH and vitamin K antagonists. Thrombolytic therapy is reserved for massive pulmonary embolism (PE) or extensive deep vein thrombosis (DVT). Inferior vena cava filters are reserved for patients with acute VTE and contraindications to anticoagulation. Retrievable filters are strongly preferred. The possibility of thoracic outlet syndrome and May-Thurner syndrome should be considered in patients with subclavian/axillary and left common iliac vein DVT, respectively in absence of identifiable triggers. The optimal duration of therapy is dictated by the presence of modifiable thrombotic risk factors. Long term anticoagulation should be considered in patients with unprovoked VTE as well as persistent prothrombotic risk factors such as cancer. Short-term therapy is sufficient for most patients with VTE associated with transient situational triggers such as major surgery. Biomarkers such as D dimer and risk assessment models such the Vienna risk prediction model offer the potential to customize VTE therapy for the individual patient. Insufficient data exist to support the integration of bleeding risk models into duration of therapy planning.

Comparison of Cardiac and Non-Cardiac Biomarkers for Risk Stratification in Elderly Patients with Non-Massive Pulmonary Embolism

Biomarkers unrelated to myocardial necrosis, such as cystatin C, copeptin, and mid-regional pro-adrenomedullin (MR-proADM), showed promise for cardiovascular risk prediction. Knowing whether they are comparable to cardiac biomarkers such as high-sensitive cardiac-troponin T (hs-cTnT) or N-terminal pro-Brain natriuretic peptide (NT-proBNP) in elderly patients with acute non-massive pulmonary embolism (NMPE) remains elusive. This study aims at comparing the prognostic accuracy of cardiac and non-cardiac biomarkers in patients with NMPE aged ≥65 years over time. In the context of the SWITCO65+ cohort, we evaluated 227 elderly patients with an available blood sample taken within one day from diagnosis. The primary study endpoint was defined as PE-related mortality and the secondary endpoint as PE-related complications. The biomarkers’ predictive ability at 1, 3, 12 and 24 months was determined using C-statistics and Cox regression. For both study endpoints, C-statistics (95% confidence interval) were stable over time for all biomarkers, with the highest value for hs-cTnT, ranging between 0.84 (0.68–1.00) and 0.80 (0.70–0.90) for the primary endpoint, and between 0.74 (0.63–0.86) and 0.65 (0.57–0.73) for the secondary endpoint. For both study endpoints, cardiac biomarkers were found to be independently associated with risk, NT-proBNP displaying a negative predictive value of 100%. Among non-cardiac biomarkers, only copeptin and MR-proADM were independent predictors of PE-related mortality but they were not independent predictors of PE-related complications, and displayed lower negative predictive values. In elderly NMPE patients, cardiac biomarkers appear to be valuable prognostic to identify very low-risk individuals.

Trial Registration: ClinicalTrials.gov NCT00973596

Predictive role of high sensitivity troponin T within four hours from presentation of acute coronary syndrome in elderly patients

Background

Previous studies indicate that the introduction of high-sensitivity troponin T (HsTnT) as a diagnostic tool for chest pain patients in the emergency department (ED) creates a high rate of false-positive tests. In the present study, we aimed to evaluate if the diagnostic performance of HsTnT for acute coronary syndrome (ACS) up to 3–4 h after presentation in elderly patients can be improved.

Methods

A total of 477 consecutive patients ≥ 75 years, admitted to in-hospital care for chest pain suspicious of ACS, were retrospectively included. HsTnT values at presentation (0 h) and at 3–4 h were analysed. Receiver operating characteristic (ROC) curves were created for absolute and relative changes from 0 to 3–4 h. ACS, non-elective percutaneous coronary intervention, coronary artery bypass grafting and death of all causes were recorded for all patients during a follow-up of 60 days. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were analysed for different HsTnT cut-off values at 0 and 3–4 h and for the combination of a HsTnT at presentation and an absolute change from 0 to 3–4 h.

Results

Twenty-seven percent of the patients had ACS and 21 % acute myocardial infarction (AMI) during the hospital stay. The standard cut-off 14 ng/L gave sensitivity and NPV for ACS of 88 and 90 % at 3–4 h. Specificity and PPV was 38 and 32 % respectively. Analysing for non-ST elevation myocardial infarction (NSTEMI) alone gave a sensitivity and NPV of 100 % but did not improve specificity and PPV. The area under the ROC-curve was larger for absolute than relative HsTnT changes from 0 to 3–4 h. A combination of HsTnT at presentation > 30 ng/L and/or a change > 5 ng/L up to 3–4 h gave a 63 % specificity and a PPV of 46 %, a 99 % sensitivity and a NPV of 99 % for NSTEMI.

Conclusion

Our study indicates that HsTnT can neither exclude nor confirm ACS within 3–4 h from presentation in patients ≥ 75 years. NSTEMI can be excluded with HsTnT within 3–4 h, but HsTnT cannot be used to rule in NSTEMI during the first 3–4 h, not even by using a combination of the initial HsTnT result and the change from 0 to 3–4 h. With combined criteria, the majority of the positive tests were still false positive. Our results indicate that in patients > 75 years, HsTnT should be used primarily as an early rule-out tool for AMI.

Prognostic Value of Biomarkers in Acute Non-massive Pulmonary Embolism: A Systematic Review and Meta-analysis

BACKGROUND

Various biomarkers have been evaluated to risk stratify patients with acute pulmonary embolism (PE). We aimed to summarize the available evidence to compare the prognostic value of three most widely studied biomarkers in normotensive patients with acute PE.

METHOD

A systematic literature review of database, including Pubmed, EMBASE and Cochrane, was done. Studies were included if those were done on patients with acute PE and serum troponin or brain natriuretic peptide and N-terminal proBNP (BNP/NT-proBNP) or Heart-type fatty acid-binding protein (H-FABP) assay was done. The primary end point was short-term all-cause mortality. The secondary end points were PE-related mortality and serious adverse events.

RESULTS

All three biomarkers were significantly associated with increased risk for short-term all-cause mortality, PE-related mortality and serious adverse events. All-cause mortality: troponin [odds ratio (OR) 4.80; 95% CI 3.25-7.08, I(2) = 54%], BNP or NT-proBNP (OR 7.98; 95% CI 4.34-14.67, I(2) = 0%); PE-related mortality: troponin (OR 3.80; 95% CI 2.74-5.27, I(2) = 0%), BNP or NT-proBNP (OR 7.57; 95% CI 2.89-19.81, I (2) = 0%) and H-FABP (OR 25.97; 95% CI 6.63-101.66, I(2) = 40%). H-FABP has the lowest negative likelihood ratio (NLR) of 0.17 for mortality followed by high-sensitive cardiac troponin T (hs-cTnT) with NLR of 0.21.

CONCLUSION

None of the biomarker identifies a subgroup of patients who can be managed as an outpatient versus patients who may get benefit from thrombolytics with certainty; however, H-FABP and hs-cTnT showed some promising results and should be investigated further.