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Al Jalbout N, Ma I, Shokoohi H, McFadden K, Kabrhel C, Giordano N, Liteplo A. A Novel Tool for Predicting an Abnormal Echocardiogram in Patients with Pulmonary Embolism: The PEACE Score. J Emerg Med 2024; 66:e403-e412. [PMID: 38311529 DOI: 10.1016/j.jemermed.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Transthoracic echocardiography (TTE) is an essential tool for risk-stratifying patients with pulmonary embolism (PE), but its availability is limited, often requiring hospitalization. Minimal research exists evaluating clinical and laboratory criteria to predict lack of abnormal TTE findings. OBJECTIVE We aimed to identify predictors associated with abnormal TTE results in patients with PE to potentially identify those safe for early discharge. METHODS In this retrospective study, we analyzed an existing database of patients with venous thromboembolism (VTE) at two academic emergency departments, including adult patients with confirmed PE who underwent TTE. The primary goal was to develop and validate a score predicting abnormal TTE, defined as presence of one of the following: right ventricle (RV) dilatation or hypokinesis, septal flattening, right heart thrombus in transit, or ejection fraction < 50%. Variables were demographic characteristics, symptoms, computed tomography (CT) RV strain, troponin T, and N-terminal prohormone of brain natriuretic peptide (NTproBNP). Stepwise logistic regression was used to identify variables independently associated with abnormal TTE. Model discrimination was evaluated using area under the curve (AUC) of the receiver operating characteristic curve. A clinical prediction rule was developed. RESULTS 530 of 2235 patients were included; 56% (297 of 530) had an abnormal TTE. The following six variables were independently associated with abnormal TTE: dyspnea, dizziness, troponin T ≥ 0.1 ng/mL, NTproBNP > 900 pg/mL, CT RV strain, and nonsubsegmental PE. A clinical prediction rule using these six criteria yielded scores between 0 and 7, performing well with AUC of 0.80 (95% CI 0.79-0.80). A score of 1 was 99.7% sensitive in identifying no abnormality. A score ≥ 5 was 98% specific for an abnormality. CONCLUSIONS The PEACE (Pulmonary Embolism and Abnormal Cardiac Echocardiogram) criteria, composed of six variables, is highly effective in predicting abnormal TTE in patients with PE, potentially identifying who is safe for early discharge from the hospital.
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Affiliation(s)
- Nour Al Jalbout
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Irene Ma
- Department of Internal Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathleen McFadden
- Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas Giordano
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Lau KK, Steinke K, Reis S, Cherukuri SP, Cejna M. Current trends in image-guided chest interventions. Respirology 2022; 27:581-599. [PMID: 35758539 PMCID: PMC9545252 DOI: 10.1111/resp.14315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/18/2022] [Indexed: 02/06/2023]
Abstract
Interventional radiology (IR) is a rapidly expanding medical subspecialty and refers to a range of image‐guided procedural techniques. The image guidance allows real‐time visualization and precision placement of a needle, catheter, wire and device to deep body structures through small incisions. Advantages include reduced risks, faster recovery and shorter hospital stays, lower costs and less patient discomfort. The range of chest interventional procedures keeps on expanding due to improved imaging facilities, better percutaneous assess devices and advancing ablation and embolization techniques. These advances permit procedures to be undertaken safely, simultaneously and effectively, hence escalating the role of IR in the treatment of chest disorders. This review article aims to cover the latest developments in some image‐guided techniques of the chest, including thermal ablation therapy of lung malignancy, targeted therapy of pulmonary embolism, angioplasty and stenting of mediastinal venous/superior vena cava occlusion, pulmonary arteriovenous malformation treatment and bronchial artery embolization for haemoptysis.
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Affiliation(s)
- Kenneth K Lau
- Monash Imaging, Monash Health, Clayton, Victoria, Australia.,School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin Steinke
- Department of Medical Imaging, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,University of Queensland School of Medicine, St Lucia, Queensland, Australia
| | - Stephen Reis
- Division of Interventional Radiology, Department of Radiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Srinivas P Cherukuri
- Division of Interventional Radiology, Department of Radiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Manfred Cejna
- Institute for Diagnostic and Interventional Radiology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
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Becattini C, Maraziti G, Vinson DR, Ng ACC, den Exter PL, Côté B, Vanni S, Doukky R, Khemasuwan D, Weekes AJ, Soares TH, Ozsu S, Polo Friz H, Erol S, Agnelli G, Jiménez D. Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis. Eur Heart J 2021; 42:3190-3199. [PMID: 34179965 DOI: 10.1093/eurheartj/ehab329] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone. METHODS AND RESULTS Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74). CONCLUSION RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - Giorgio Maraziti
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - David R Vinson
- Department of Emergency Medicine, The Permanente Medical Group and the Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Austin C C Ng
- Cardiology Department, Concord Hospital, The University of Sydney, Concord, NSW, Australia
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Benoit Côté
- Département de Médecine Interne, Hôpital de l'Enfant-Jésus du CHU de Québec, Université Laval, Québec, Canada
| | - Simone Vanni
- Emergency Medicine Unit, Empoli, Azienda Usl Toscana Centro, Italy
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA
| | - Danai Khemasuwan
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Anthony J Weekes
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Thiago Horta Soares
- Internal Medicine Division, Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brazil
| | - Savas Ozsu
- Department of Pulmonary Medicine, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Hernan Polo Friz
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Serhat Erol
- University of Ankara School of Medicine, Pulmonary Diseases Department, Ankara, Turkey
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá (IRYCIS), Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Rehman NU, Dar MI, Bansal M, Kasliwal RR. Clinical outcomes of submassive pulmonary embolism thrombolysis-an Indian experience. Egypt Heart J 2020; 72:87. [PMID: 33315173 PMCID: PMC7736429 DOI: 10.1186/s43044-020-00123-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute pulmonary thromboembolism is the most dangerous presentation of venous thromboembolic disease. The role of thrombolysis in massive pulmonary embolism has been studied extensively, but the same is not there for submassive pulmonary embolism. This study is aimed at evaluating the effects of thrombolysis in acute submassive pulmonary embolism. This was a prospective, case-control, observational study. Patients presenting with acute submassive pulmonary embolism were divided into thrombolysis group and control group depending on whether they received thrombolysis plus anticoagulation or anticoagulation only, respectively. RESULTS A total of 86 patients were included in the study. Forty-two patients were in the thrombolysis group, and 44 patients were in the control group. The mean ± SD age in the control and thrombolysis groups was 63.3 ± 14.7 and 56.4 ± 13.8 years, respectively. The two groups were well matched in sex distribution and associated comorbidities like COPD, active surgery, major trauma, and immobilization. On echocardiography, dilated RA/RV in pre-treatment vs. post-treatment was seen in 20 (45.5%) vs. 20 (45.5%) in the control group and 26 (61.9%) vs. 11 (26.2%) in the thrombolysis group. Similarly, RV systolic dysfunction in pre-treatment vs. post-treatment was seen in 24 (54.5%) vs. 21 (47.7%) in the control group and 22 (52.4%) vs. 8 (19.0%) in the thrombolysis group. Pulmonary artery pressure in pre-treatment vs. post-treatment was 64.4 ± 15.0 vs. 45.9 ± 9.9 mmHg in the control group and 68.3 ± 17.4 vs. 31.4 ± 6.9 mmHg in the thrombolysis group. In control vs. thrombolysis group, there were 5 vs. 1 death, 6 vs. 1 hemodynamic decompensation, and 6 vs. 1 patient needing mechanical ventilation. CONCLUSION Thrombolysis in submassive pulmonary embolism is associated with better right ventricular functions, lower pulmonary artery pressures, and comparable mortality rates.
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Affiliation(s)
| | - Mohd Iqbal Dar
- Department of Cardiology, SKIMS Soura, Srinagar, Jammu and Kashmir, 190011, India.
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The new prognostic factor for pulmonary embolism: The ratio of monocyte count to HDL cholesterol. Am J Emerg Med 2020; 46:212-216. [PMID: 33071082 DOI: 10.1016/j.ajem.2020.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/10/2020] [Accepted: 07/10/2020] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Aim of this study is to investigate effectiveness of the monocyte to HDL cholesterol ratio in patients diagnosed with pulmonary embolism for predicting intra-hospital mortality. METHOD A total of 269 patients diagnosed with pulmonary embolism in the emergency clinic were included in the study. Study was conducted retrospectively. Pulmonary Embolism Severity Index (PESI), Monocyte count and high density lipoprotein cholesterol (HDL) values were determined. MHR values of the patients were calculated. SPSS 26 package program was used to investigate the effectiveness of MHR in predicting mortality. FINDINGS Mean age of the patients was 64.51 ± 12.4 years. PESI, Number of monocytes and MHR were significantly higher in the group with mortality than the group without mortality (p < .05). HDL values were significantly lower (p < .05) in mortality group. Sensitivity of MHR 19 cut off value was 89.3%, and its specificity was 82.0%. CONCLUSION Use of predictors for mortality estimation in patients diagnosed with acute pulmonary embolism is important for faster administration of treatment modalities. We think MHR values can be used as a strong predictor according to the hemogram parameters and biochemical results.
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El-Menyar A, Sathian B, Al-Thani H. Elevated serum cardiac troponin and mortality in acute pulmonary embolism: Systematic review and meta-analysis. Respir Med 2019; 157:26-35. [PMID: 31476570 DOI: 10.1016/j.rmed.2019.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/08/2019] [Accepted: 08/20/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate whether elevated levels of cardiac troponin increases the risk of mortality in patients with acute PE. METHODS We conducted a systematic review and meta-analysis with rigorous statistical evaluation using publications (2000-2018) from Cochrane Library, MEDLINE, PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, and Google Scholar databases. We searched for retrospective, prospective, and randomized controlled trials (RCT) or quasi-RCT studies that assessed the effect of elevated troponin versus normal levels on the outcomes of PE. The main outcome of interest was all-cause mortality. Extracted data included authors, the origin of studies, source population, study settings and duration, inclusion/exclusion criteria, data sources and measurement, sample size, and mortality. Data heterogeneity was assessed using the Cochrane Q homogeneity test with a significance set at p < 0.10. If the studies were statistically homogeneous, a fixed effect model was selected. RESULTS Out of 1825 references, 46 analytical studies were included with a total of 10842 patients with PE. The effect of elevated troponin on mortality had a pooled odd ratio (OR) of 4.33 for all studies, 3.7for HsTnT, 14.81 for HsTnI, 7.85 for cTnT, 2.81 for cTnI, 9.02 for low-risk PE and 4.80 for 90-day mortality. The pooled negative likelihood ratios for all-cause mortality using HsTnI, cTnI and cTnT assay were 0.21, 0.33 and 0.65, respectively. CONCLUSION Regardless of the troponin assay, pooled analysis indicates that elevated troponin is significantly associated with higher mortality in patients with PE.
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Affiliation(s)
- Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad Medical Corporation (HMC), Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Brijesh Sathian
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma & Vascular Surgery, HMC, Doha, Qatar
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Barco S, Mahmoudpour SH, Planquette B, Sanchez O, Konstantinides SV, Meyer G. Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2019; 40:902-910. [PMID: 30590531 PMCID: PMC6416533 DOI: 10.1093/eurheartj/ehy873] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/14/2018] [Accepted: 12/03/2018] [Indexed: 12/22/2022] Open
Abstract
AIMS Patients with acute pulmonary embolism (PE) classified as low risk by the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI), or the Hestia criteria may be considered for early discharge. We investigated whether the presence of right ventricular (RV) dysfunction may aggravate the early prognosis of these patients. METHODS AND RESULTS We did a systematic review and meta-analysis of studies including low-risk patients with acute PE to investigate the prognostic value of RV dysfunction. Diagnosis of RV dysfunction was based on echocardiography or computed tomography pulmonary angiography. In addition, we investigated the prognostic value of elevated troponin or natriuretic peptide levels. The primary outcome was all-cause mortality at 30 days or during hospitalization. We included 22 studies (N = 3295 low-risk patients) in the systematic review: 21 were selected for quantitative analysis. Early all-cause mortality rates in patients with vs. without RV dysfunction on imaging were 1.8% [95% confidence interval (CI) 0.9-3.5%] vs. 0.2% (95% CI 0.03-1.7%), respectively, [odds ratio (OR) 4.19, 95% CI 1.39-12.58]. For troponins, rates were 3.8% (95% CI 2.1-6.8%) vs. 0.5% (95% CI 0.2-1.3%), (OR 6.25, 95% CI 1.95-20.05). For natriuretic peptides, only data on early PE-related mortality were available: rates were 1.7% (95% CI 0.4-6.9%) vs. 0.4% (95% CI 0.1-1.1%), (OR 3.71, 95% CI 0.81-17.02). CONCLUSIONS In low-risk patients with acute PE, the presence of RV dysfunction on admission was associated with early mortality. Our results may have implications for the management of patients who appear at low risk based on clinical criteria alone, but present with RV dysfunction as indicated by imaging findings or laboratory markers.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Haemostasis (CTH), University Medical Centre of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
| | - Seyed Hamidreza Mahmoudpour
- Center for Thrombosis and Haemostasis (CTH), University Medical Centre of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
- Department of Biometry and Bioinformatics, Institute for Medical Biostatistics, Epidemiology, and Informatics (IMBEI), University Medical Centre of the Johannes Gutenberg University, Obere Zahlbacher Straße 69, Mainz, Germany
| | - Benjamin Planquette
- F-CRIN INNOVTE, Hôpital Nord, CHU Saint Etienne, Avenue Albert Raimond, Saint Priest en Jarez (Saint Etienne), France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 1140, 20 rue Leblanc, Paris, France
| | - Olivier Sanchez
- F-CRIN INNOVTE, Hôpital Nord, CHU Saint Etienne, Avenue Albert Raimond, Saint Priest en Jarez (Saint Etienne), France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 1140, 20 rue Leblanc, Paris, France
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis (CTH), University Medical Centre of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, University General Hospital, Alexandroupolis, Greece
| | - Guy Meyer
- F-CRIN INNOVTE, Hôpital Nord, CHU Saint Etienne, Avenue Albert Raimond, Saint Priest en Jarez (Saint Etienne), France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 1140, 20 rue Leblanc, Paris, France
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Bledsoe JR, Woller SC, Stevens SM, Aston V, Patten R, Allen T, Horne BD, Dong L, Lloyd J, Snow G, Madsen T, Elliott CG. Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization. Chest 2018; 154:249-256. [DOI: 10.1016/j.chest.2018.01.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/17/2018] [Accepted: 01/19/2018] [Indexed: 12/18/2022] Open
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Huang SJ, Nalos M, Smith L, Rajamani A, McLean AS. The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research. Intensive Care Med 2018; 44:868-883. [PMID: 29789861 DOI: 10.1007/s00134-018-5211-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/05/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Many echocardiographic indices (or methods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study. METHODS Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized. RESULTS Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices. CONCLUSIONS TAPSE seemed to be the most popular index in the last 2-3 years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.
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Affiliation(s)
- Stephen J Huang
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
| | - Marek Nalos
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Louise Smith
- Cardiovascular Ultrasound Laboratory, Intensive Care Unit, Nepean Hospital, Sydney, NSW, Australia
| | - Arvind Rajamani
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Anthony S McLean
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Keller K, Beule J, Balzer JO, Dippold W. Renal function as a cofactor for risk stratification and short-term outcome in acute pulmonary embolism. Exp Gerontol 2017; 100:11-16. [DOI: 10.1016/j.exger.2017.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 10/03/2017] [Accepted: 10/07/2017] [Indexed: 12/15/2022]
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11
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Spirk D, Aujesky D, Husmann M, Hayoz D, Baldi T, Frauchiger B, Banyai M, Baumgartner I, Kucher N. Cardiac troponin testing and the simplified Pulmonary Embolism Severity Index. Thromb Haemost 2017; 106:978-84. [DOI: 10.1160/th11-06-0371] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 07/15/2011] [Indexed: 12/13/2022]
Abstract
SummaryA low simplified Pulmonary Embolism Severity Index (sPESI), defined as age ≤80 years and absence of systemic hypotension, tachycardia, hypoxia, cancer, heart failure, and lung disease, identifies low-risk patients with acute pulmonary embolism (PE). It is unknown whether cardiac troponin testing improves the prediction of clinical outcomes if the sPESI is not low. In the prospective Swiss Venous Thromboembolism Registry, 369 patients with acute PE and a troponin test (conventional troponin T or I, highly sensitive troponin T) were enrolled from 18 hospitals. A positive test result was defined as a troponin level above the manufacturers assay threshold. Among the 106 (29%) patients with low sPESI, the rate of mortality or PE recurrence at 30 days was 1.0%. Among the 263 (71%) patients with high sPESI, 177 (67%) were troponin-negative and 86 (33%) troponin-positive; the rate of mortality or PE recurrence at 30 days was 4.6% vs. 12.8% (p=0.015), respectively. Overall, risk assessment with a troponin test (hazard ratio [HR] 3.39, 95% confidence interval [CI] 1.38–8.37; p=0.008) maintained its prognostic value for mortality or PE recurrence when adjusted for sPESI (HR 5.80, 95%CI 0.76–44.10; p=0.09). The combination of sPESI with a troponin test resulted in a greater area under the receiver-operating characteristic curve (HR 0.72, 95% CI 0.63–0.81) than sPESI alone (HR 0.63, 95% CI 0.57–0.68) (p=0.023). In conclusion, although cardiac troponin testing may not be required in patients with a low sPESI, it adds prognostic value for early death and recurrence for patients with a high sPESI.
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Omar HR, Mirsaeidi M, Weinstock MB, Enten G, Mangar D, Camporesi EM. Syncope on presentation is a surrogate for submassive and massive acute pulmonary embolism. Am J Emerg Med 2017; 36:297-300. [PMID: 29146419 DOI: 10.1016/j.ajem.2017.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION There are conflicting data regarding the prognostic value of syncope in patients with acute pulmonary embolism (APE). METHODS We retrospectively reviewed data of 552 consecutive adults with computed tomography pulmonary angiogram-confirmed APE to determine the correlates and outcome of the occurrence of syncope at the time of presentation. RESULTS Among 552 subjects with APE (mean age 54years, 47% men), syncope occurred in 12.3% (68/552). Compared with subjects without syncope, those with syncope were more likely to have admission systolic blood pressure<90mmHg (odds ratio (OR) 5.788, P<0.001), and an oxygen saturation<88% on room air (OR 5.560, P<0.001), right ventricular dilation (OR 2.480, P=0.006), right ventricular hypokinesis (OR 2.288, P=0.018), require mechanical ventilation for respiratory failure (OR 3.152, P=0.014), and more likely to receive systemic thrombolysis (OR 4.722, P=0.008). On multivariate analysis, syncope on presentation was an independent predictor of a massive APE (OR 2.454, 95% CI 1.109-5.525, P=0.03) after adjusting for patients' age, sex, requirement of antibiotics throughout hospitalization, peak serum creatinine, admission oxygen saturation<88% and admission heart rate>100bpm. There was no difference in mortality in cases with APE with or without syncope (P=0.412). CONCLUSION Syncope at the onset of pulmonary embolization is a surrogate for submassive and massive APE but is not associated with higher in-hospital mortality.
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Affiliation(s)
- Hesham R Omar
- Internal Medicine Department, Mercy Medical Center, Clinton, IA, USA.
| | - Mehdi Mirsaeidi
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Miami, Miller school of Medical, FL, USA; Section of Pulmonary, Department of Medicine, Miami VA Medical Center, Miami, FL, USA
| | - Michael B Weinstock
- Department of Emergency Medicine, Adena Regional Medical Center, Chillicothe, OH, USA; Department of Emergency Medicine, Wexner Medical Center, Ohio State University, Columbus, OH, USA
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Abstract
OBJECTIVE The purpose of this article is to describe the indications for and approach to catheter-based treatment of acute venous thromboembolism (VTE). CONCLUSION Catheter-based treatment of VTE is a viable adjunct to anticoagulant therapy and is being rapidly adopted around the United States. Early data suggest that these therapies reduce postthrombotic sequelae and improve quality of life, but bleeding events are still frequent, particularly at low-volume centers. Protocols need to be standardized to improve patient care.
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Keller K, Geyer M, Coldewey M, Beule J, Balzer JO, Dippold W. Elevated systolic pulmonary artery pressure for prediction of myocardial necrosis and right ventricular dysfunction in acute pulmonary embolism. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Echocardiography does not predict mortality in hemodynamically stable elderly patients with acute pulmonary embolism. Thromb Res 2016; 145:67-71. [PMID: 27498122 DOI: 10.1016/j.thromres.2016.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 07/04/2016] [Accepted: 07/26/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The evidence on the prognostic value of transthoracic echocardiography (TTE) in elderly, hemodynamically stable patients with Pulmonary Embolism (PE) is limited. OBJECTIVES To evaluate the prevalence of common echocardiographic signs of right ventricular (RV) dysfunction and their prognostic impact in hemodynamically stable patients aged ≥65years with acute PE in a prospective multicenter cohort. METHODS TTE was performed by cardiologists. We defined RV dysfunction as a RV/left ventricular ratio >0.9 or RV hypokinesis (primary definition) or the presence of ≥1 or ≥2 of 6 predefined echocardiographic signs (secondary definitions). Outcomes were overall mortality and mortality/non-fatal recurrent venous thromboembolism (VTE) at 30days, adjusting for the Pulmonary Embolism Severity Index risk score and highly sensitive troponin T values. RESULTS Of 400 patients, 36% had RV dysfunction based on our primary definition, and 81% (≥1 sign) and 53% (≥2 signs) based on our secondary definitions, respectively. Using our primary definition, there was no association between RV dysfunction and mortality (adjusted HR 0.90, 95% CI 0.31-2.58) and mortality/non-fatal VTE (adjusted HR 1.09, 95% CI 0.40-2.98). Similarly, there was no statistically significant association between the presence of ≥1 or ≥2 echocardiographic signs (secondary definitions) and clinical outcomes. CONCLUSION The prevalence of echocardiographic RV dysfunction varied widely depending upon the definition used. There was no association between RV dysfunction and clinical outcomes. Thus, TTE may not be suitable as a stand-alone risk assessment tool in elderly patients with acute PE. CLINICAL TRIAL REGISTRATION http://clinicaltrials.gov. Identifier: NCT00973596.
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Elias A, Mallett S, Daoud-Elias M, Poggi JN, Clarke M. Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. BMJ Open 2016; 6:e010324. [PMID: 27130162 PMCID: PMC4854007 DOI: 10.1136/bmjopen-2015-010324] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes. DESIGN Systematic review and meta-analysis. DATA SOURCES OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature. ELIGIBILITY CRITERIA Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE. DATA EXTRACTION Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers. DATA ANALYSIS Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy. RESULTS We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate). CONCLUSIONS We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.
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Affiliation(s)
- Antoine Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
- DPhil Programme in Evidence-Based Healthcare, University of Oxford, Oxford, UK
| | - Susan Mallett
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marie Daoud-Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Jean-Noël Poggi
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Mike Clarke
- Northern Ireland Network for Trials Methodology Research, Queen's University Belfast, Belfast, UK
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Kohn CG, Peacock WF, Fermann GJ, Bunz TJ, Crivera C, Schein JR, Coleman CI. External validation of the In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) multivariable prediction rule. Int J Clin Pract 2016; 70:82-8. [PMID: 26575855 DOI: 10.1111/ijcp.12748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To validate the In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) multivariable prediction rule using admission claims data. STUDY DESIGN Retrospective claims database analysis. METHODS This analysis was performed using Humana admission claims data from January 2007 to March 2014. We included adult patients admitted for their first PE during this period (International Classification of Diseases, ninth edition, Clinical Modification code of 415.1x in in the primary position or secondary position when accompanied by a primary code for a PE complication). The IMPACT rule, consisting of age plus 11 comorbidities, was used to estimate patients' probability of in-hospital mortality and classify risk. Low risk was defined as in-hospital mortality ≤ 1.5%. IMPACT was evaluated by evaluating prognostic test characteristic values and 95% confidence intervals (CIs). RESULTS A total of 23,858 patients admitted for PE were included, and 3.3% died in-hospital. The IMPACT prediction rule classified 2371 (9.9%) as low-risk; with a sensitivity of 97.6%, 95% CI: 96.1-98.5, specificity of 10.2%, 95% CI: 9.8-10.6, negative and positive predictive values of 99.2% (95% CI: 98.7-99.5) and 3.5% (95% CI: 3.3-3.8) and c-statistic of 0.70, 95% CI: 0.0.68-0.72, for in-hospital mortality. IMPACT classified 42.7% of patients < 65 years old as low-risk; with a sensitivity, specificity and c-statistic of 85.0%, 95% CI: 77.4-90.5, 43.3%, 95% CI: 42.0-44.7 and 0.74, 95% CI: 0.69-0.78, respectively. CONCLUSION The IMPACT prediction rule was valid when implemented in a database consisting largely of Medicare claims. Following further external validation and direct comparison to commonly used clinical prediction rules, IMPACT may become a valuable tool for payers and hospitals wishing to retrospectively assess whether their PE patients are being kept hospitalized for the optimal period of time.
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Affiliation(s)
- C G Kohn
- Department of Pharmacy Practice and Administration, University of Saint Joseph School of Pharmacy, Hartford, CT, USA
- Evidence-based Practice Center, UCONN/Hartford Hospital, Hartford, CT, USA
| | - W F Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - G J Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - T J Bunz
- Program Evaluation & Pharmacy Analytics, Aetna, Hartford, CT, USA
| | - C Crivera
- Janssen Scientific Affairs, LLC, Raritan, NJ, USA
| | - J R Schein
- Janssen Scientific Affairs, LLC, Raritan, NJ, USA
| | - C I Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
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Coleman CI, Kohn CG, Crivera C, Schein JR, Peacock WF. Validation of the multivariable In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) prediction rule within an all-payer inpatient administrative claims database. BMJ Open 2015; 5:e009251. [PMID: 26510731 PMCID: PMC4636647 DOI: 10.1136/bmjopen-2015-009251] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To validate the In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) prediction rule, in a database consisting only of inpatient claims. DESIGN Retrospective claims database analysis. SETTING The 2012 Healthcare Cost and Utilization Project National Inpatient Sample. PARTICIPANTS Pulmonary embolism (PE) admissions were identified by an International Classification of Diseases, ninth edition (ICD-9) code either in the primary position or secondary position when accompanied by a primary code for a PE complication. The multivariable IMPACT rule, which includes age and 11 comorbidities, was used to estimate patients' probability of in-hospital mortality and classify them as low or higher risk (≤1.5% deemed low risk). PRIMARY AND SECONDARY OUTCOME MEASURES The rule's sensitivity, specificity, positive and negative predictive values (PPV and NPV) and area under the receiver operating characteristic curve statistic for predicting in-hospital mortality with accompanying 95% CIs. RESULTS A total of 34,108 admissions for PE were included, with a 3.4% in-hospital case-fatality rate. IMPACT classified 11, 025 (32.3%) patients as low risk, and low risk patients had lower in-hospital mortality (OR, 0.17, 95% CI 0.13 to 0.21), shorter length of stay (-1.2 days, p<0.001) and lower total treatment costs (-$3074, p<0.001) than patients classified as higher risk. IMPACT had a sensitivity of 92.4%, 95% CI 90.7 to 93.8 and specificity of 33.2%, 95% CI 32.7 to 33.7 for classifying mortality risk. It had a high NPV (>99%), low PPV (4.6%) and an AUC of 0.74, 95% CI 0.73 to 0.76. CONCLUSIONS The IMPACT rule appeared valid when used in this all payer, inpatient only administrative claims database. Its high sensitivity and NPV suggest the probability of in-hospital death in those classified as low risk by IMPACT was minimal.
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Affiliation(s)
- Craig I Coleman
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Christine G Kohn
- University of Saint Joseph School of Pharmacy, Hartford, Connecticut, USA
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19
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Abstract
Pulmonary embolism (PE) is a common diagnosis in critical care. Depending on the severity of clot burden, the clinical picture ranges from nearly asymptomatic to cardiovascular collapse. The signs and symptoms of PE are nonspecific. The clinician must have a high index of suspicion to make the diagnosis. PE is risk stratified into 3 categories: low-risk, submassive, and massive. Submassive PE remains the most challenging with regard to initial and long-term management. Little consensus exists as to the appropriate tests for risk stratification and therapy. This article reviews the current literature and a suggested approach to these patients.
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Affiliation(s)
- Laurence W Busse
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Jason S Vourlekis
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
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20
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Prognostic Value of Biomarkers in Acute Non-massive Pulmonary Embolism: A Systematic Review and Meta-analysis. Lung 2015; 193:639-51. [PMID: 26134045 DOI: 10.1007/s00408-015-9752-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/15/2015] [Indexed: 10/23/2022]
Abstract
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.
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21
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Bajaj A, Saleeb M, Rathor P, Sehgal V, Kabak B, Hosur S. Prognostic value of troponins in acute nonmassive pulmonary embolism: A meta-analysis. Heart Lung 2015; 44:327-34. [DOI: 10.1016/j.hrtlng.2015.03.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 03/24/2015] [Accepted: 03/25/2015] [Indexed: 11/30/2022]
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Kohn CG, Mearns ES, Parker MW, Hernandez AV, Coleman CI. Prognostic Accuracy of Clinical Prediction Rules for Early Post-Pulmonary Embolism All-Cause Mortality. Chest 2015; 147:1043-1062. [DOI: 10.1378/chest.14-1888] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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23
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Keller K, Beule J, Schulz A, Coldewey M, Dippold W, Balzer JO. Cardiac troponin I for predicting right ventricular dysfunction and intermediate risk in patients with normotensive pulmonary embolism. Neth Heart J 2014; 23:55-61. [PMID: 25501268 PMCID: PMC4268209 DOI: 10.1007/s12471-014-0628-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Right ventricular dysfunction (RVD) and cardiac troponin I (cTnI) are important tools for risk stratification in pulmonary embolism (PE). We investigate the association of RVD and cTnI in normotensive PE patients and calculate a cTnI cut-off level for predicting RVD and submassive PE. Methods Clinical, laboratory, radiological and echocardiagraphic data were analysed. Patients were categorised into groups with or without RVD and compared focussing on cTnI. Effectiveness of cTnI for predicting RVD and submassive PE was tested. Results One hundred twenty-nine normotensive PE patients, 71 with and 58 without RVD, were included. Patients with RVD were older (75.0 years (61.3/81.0) vs. 66.0 years (57.7/75.1), P = 0.019). cTnI (0.06 ng/ml (0.02/0.23) vs. 0.01 ng/ml (0.00/0.03), P < 0.0001) and D-dimer values (2.00 mg/l (1.08/4.05) vs. 1.23 mg/l (0.76/2.26), P = 0.016) were higher in PE with RVD. cTnI was associated with RVD (OR 3.95; 95 % CI 1.95–8.02, p = 0.00014). AUC for cTnI diagnosing RVD was 0.79, and for submassive PE0.87. Cut-off values for cTnI predicting RVD and submassive PE were 0.01 ng/ml, with a negative predictive value of 73 %. cTnI was positively correlated with age, D-dimer and creatinine. Conclusions In normotensive PE patients, cTnI is helpful for risk stratification and excluding RVD. cTnI elevation is correlated with increasing age and reduced kidney function.
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Affiliation(s)
- K Keller
- Department of Medicine II, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany,
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Ahmed AN, Blonde K, Hackam D, Iansavichene A, Mrkobrada M. Prognostic significance of elevated troponin in non-cardiac hospitalized patients: a systematic review and meta-analysis. Ann Med 2014; 46:653-63. [PMID: 25307362 DOI: 10.3109/07853890.2014.959558] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cardiac biomarker troponin can be elevated in patients without a primary cardiac diagnosis and may have prognostic value. We conducted a systematic review to estimate the prevalence and prognostic significance of elevated troponin levels in patients admitted to hospital without a primary cardiac diagnosis. Literature search was done using MEDLINE (1946 to November 2012), EMBASE (1974 to Week 45, 2012), and Cochrane Central Register of Controlled Trials (November 2012). Two independent investigators reviewed full-text studies for final inclusion. We included studies of patients admitted without a primary cardiac diagnosis. Eligible studies compared adverse outcomes in patients with normal versus elevated troponin levels. Twenty-seven studies were included in the meta-analysis. Elevated troponin was associated with increased in-hospital and 30-day mortality (25 studies, 7255 patients, OR 3.88, 95% CI 2.90-5.19, P < 0.0001). Elevated troponin was also associated with increased risk of long-term mortality at 6 months (9 studies, 5368 patients, OR 4.21, 95% CI 1.84-9.64, P < 0.00001). Troponin is an independent predictor of short-term mortality with a pooled adjusted OR of 2.36, 95% CI 1.47-3.76, P < 0.0003. In conclusion, elevated troponin in non-cardiac patients is independently associated with increased mortality.
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Affiliation(s)
- Amna N Ahmed
- Department of Medicine, London Health Sciences Centre , London, Ontario , Canada
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25
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Pulmonary Embolism Rule-out Criteria vs D-dimer testing in low-risk patients for pulmonary embolism: a retrospective study. Am J Emerg Med 2014; 32:609-13. [DOI: 10.1016/j.ajem.2014.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/09/2014] [Accepted: 03/10/2014] [Indexed: 11/19/2022] Open
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26
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Cho JH, Kutti Sridharan G, Kim SH, Kaw R, Abburi T, Irfan A, Kocheril AG. Right ventricular dysfunction as an echocardiographic prognostic factor in hemodynamically stable patients with acute pulmonary embolism: a meta-analysis. BMC Cardiovasc Disord 2014; 14:64. [PMID: 24884693 PMCID: PMC4029836 DOI: 10.1186/1471-2261-14-64] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 05/01/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We investigated whether right ventricular dysfunction (RVD) as assessed by echocardiogram can be used as a prognostic factor in hemodynamically stable patients with acute pulmonary embolism (PE). Short-term mortality has been investigated only in small studies and the results have been controversial. METHODS A PubMed search was conducted using two keywords, "pulmonary embolism" and "echocardiogram", for articles published between January 1st 1998 and December 31st 2011. Out of 991 articles, after careful review, we found 12 articles that investigated the implications of RVD as assessed by echocardiogram in predicting short-term mortality for hemodynamically stable patients with acute PE. We conducted a meta-analysis of these data to identify whether the presence of RVD increased short-term mortality. RESULTS Among 3283 hemodynamically stable patients with acute PE, 1223 patients (37.3%) had RVD, as assessed by echocardiogram, while 2060 patients (62.7%) had normal right ventricular function. Short-term mortality was reported in 167 (13.7%) out of 1223 patients with RVD and in 134 (6.5%) out of 2060 patients without RVD. Hemodynamically stable patients with acute PE who had RVD as assessed by echocardiogram had a 2.29-fold increase in short-term mortality (odds ratio 2.29, 95% confidence interval 1.61-3.26) compared with patients without RVD. CONCLUSIONS In hemodynamically stable patients with acute PE, RVD as assessed by echocardiogram increases short-term mortality by 2.29 times. Consideration should be given to obtaining echocardiogram to identify high-risk patients even if they are hemodynamically stable.
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Affiliation(s)
- Jae Hyung Cho
- Department of Hospital Medicine, Cleveland Clinic, OH, 9500 Euclid Avenue, M2-Annex, Cleveland, OH 44195, USA.
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27
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Trujillo-Santos J, den Exter PL, Gómez V, Del Castillo H, Moreno C, van der Hulle T, Huisman MV, Monreal M, Yusen RD, Jiménez D. Computed tomography-assessed right ventricular dysfunction and risk stratification of patients with acute non-massive pulmonary embolism: systematic review and meta-analysis. J Thromb Haemost 2013; 11:1823-32. [PMID: 23964984 DOI: 10.1111/jth.12393] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 08/15/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND The ability of computed tomography (CT)-assessed right ventricular dysfunction (RVD) to identify normotensive patients with acute pulmonary embolism (PE) at high risk of mortality or adverse outcome lacks clarity. METHODS AND RESULTS We performed a systematic review and a meta-analysis of studies in normotensive patients with acute PE to assess the prognostic value of CT-assessed RVD for death and a predefined composite outcome of PE-related complications. We conducted unrestricted searches of MEDLINE and EMBASE from 1980 to March 2013, and used the terms 'computed tomography', 'pulmonary embolism', and 'prognos*'. We used a random-effects model to pool study results, funnel-plot inspection to evaluate for publication bias, and I(2) testing to assess for heterogeneity. The analysis included data from 10 studies (2288 patients). Overall, 99 of 1268 patients with RVD assessed by CT died (7.8%; 95% confidence interval [CI] 6.3-9.3) as compared with 52 of 1020 without RVD (5.1%; 95% CI 3.7-6.4). CT-assessed RVD had significant associations with mortality (odds ratio [OR] 1.8; 95% CI 1.3-2.6), with death resulting from PE (OR 7.4; 95% CI 1.4-39.5), and with PE-related complications (OR 2.4; 95% CI 1.2-4.7). Pooled likelihood ratios (LRs) were not extreme (negative LR 0.71; 95% CI 0.57-0.89; and positive LR 1.27; 95% CI 1.12-1.43). CONCLUSIONS Although RVD assessed by CT showed an association with an increased risk of mortality in patients with hemodynamically stable PE, it resulted in only small increases in the ability to classify risk.
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Affiliation(s)
- J Trujillo-Santos
- Department of Medicine, Santa Lucía Hospital, Cartagena, Murcia, Spain
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Nicolaides A, Fareed J, Kakkar AK, Comerota AJ, Goldhaber SZ, Hull R, Myers K, Samama M, Fletcher J, Kalodiki E, Bergqvist D, Bonnar J, Caprini JA, Carter C, Conard J, Eklof B, Elalamy I, Gerotziafas G, Geroulakos G, Giannoukas A, Greer I, Griffin M, Kakkos S, Lassen MR, Lowe GDO, Markel A, Prandoni P, Raskob G, Spyropoulos AC, Turpie AG, Walenga JM, Warwick D. Thrombolytic Therapy. Clin Appl Thromb Hemost 2013; 19:198-204. [DOI: 10.1177/1076029612474840o] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Kilinc G, Dogan OT, Berk S, Epozturk K, Ozsahin SL, Akkurt I. Significance of serum cardiac troponin I levels in pulmonary embolism. J Thorac Dis 2013. [PMID: 23205283 DOI: 10.3978/j.issn.2072-1439.2012.10.13] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Some biomarkers can be helpful in the diagnosis of pulmonary embolism (PE) and determining of severity and prognosis of the disease. In this study, we aimed to analyze the elevated cardiac troponin I (cTnI) levels and its association with electrocardiography (ECG) and transthoracic echocardiography (TTE) findings in patients with PE. METHODS Totally 106 patients with suspected PE were included in the study. PE was confirmed in 63 of them, whereas it was excluded in the remaining 43 patients. Levels of cTnI were measured in all patients before the prescription of the anticoagulation therapy. RESULTS High cTnI levels were found in 50.8% of patients with PE, and in 11.6% of patients without PE (P<0.001). Sensitivity and specificity of the test for the diagnosis of PE were 50.7%, 88.3% respectively. ECG findings were similar in PE patients having either elevated or normal cTnI levels. Approximately 75% of the PE patients with high cTnI had normal ECG findings; the most common pathological changes seen in ECG were S1Q3T3 pattern (~31%). TTE findings were not found to be distinguishing in the patients with suspected PE and high cTnI levels. Pulmonary hypertension (PHT) was the most common echocardiographic finding (~74%) in patients with PE and elevated cTnI levels. However, there was not a statistically significant difference between TTE findings in PE patients with increased and normal cTnI levels. CONCLUSIONS In patients presenting with clinical, electrocardiographic and echocardiographic features suggesting pulmonary embolism, increased serum cTnI levels endorse the diagnosis of severe PE.
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Affiliation(s)
- Gonca Kilinc
- Nafiz Kurt Bafra Public Hospital, Department of Chest Diseases, Samsun, Turkey
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Squizzato A. New prospective for the management of low-risk pulmonary embolism: prognostic assessment, early discharge, and single-drug therapy with new oral anticoagulants. SCIENTIFICA 2012; 2012:502378. [PMID: 24278706 PMCID: PMC3820448 DOI: 10.6064/2012/502378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/05/2012] [Indexed: 06/02/2023]
Abstract
Patients with pulmonary embolism (PE) can be stratified into two different prognostic categories, based on the presence or absence of shock or sustained arterial hypotension. Some patients with normotensive PE have a low risk of early mortality, defined as <1% at 30 days or during hospital stay. In this paper, we will discuss the new prospective for the optimal management of low-risk PE: prognostic assessment, early discharge, and single-drug therapy with new oral anticoagulants. Several parameters have been proposed and investigated to identify low-risk PE: clinical prediction rules, imaging tests, and laboratory markers of right ventricular dysfunction or injury. Moreover, outpatient management has been suggested for low-risk PE: it may lead to a decrease in unnecessary hospitalizations, acquired infections, death, and costs and to an improvement in health-related quality of life. Finally, the main characteristics of new oral anticoagulant drugs and the most recent published data on phase III trials on PE suggest that the single-drug therapy is a possible suitable option. Oral administration, predictable anticoagulant responses, and few drug-drug interactions of direct thrombin and factor Xa inhibitors may further simplify PE home therapy avoiding administration of low-molecular-weight heparin.
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Affiliation(s)
- Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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Squizzato A, Donadini MP, Galli L, Dentali F, Aujesky D, Ageno W. Prognostic clinical prediction rules to identify a low-risk pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost 2012; 10:1276-90. [PMID: 22498033 DOI: 10.1111/j.1538-7836.2012.04739.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Prognostic assessment is important for the management of patients with a pulmonary embolism (PE). A number of clinical prediction rules (CPRs) have been proposed for stratifying PE mortality risk. The aim of this systematic review was to assess the performance of prognostic CPRs in identifying a low-risk PE. METHODS MEDLINE and EMBASE databases were systematically searched until August 2011. Derivation and validation studies that assessed the performance of prognostic CPRs in predicting adverse events-risk in PE patients were included. Weighted mean proportion and 95% confidence intervals (CIs) of adverse events were then calculated and pooled using a fixed and a random-effects model. Statistical heterogeneity was evaluated through the use of I(2) statistics. RESULTS Of 1125 references in the original search, 33 relevant articles were included. Nine CPRs were assessed in 37 cohorts, for a total of 35,518 patients. Pulmonary Embolism Severity Index and prognostic Geneva CPR were investigated in 22 and 6 cohorts, respectively. Eleven (29.7%) cohorts were of high quality. The median follow-up was 30 days. In low-risk PE patients, pooled short-term mortality (within 14 days or less) was 0.7% (95% CI 0.3-1.1%, random-effects model; I(2) = 49.6%), 30-day mortality was 1.7% (95% CI 1.1-2.3%, random-effects model; I(2) = 82.4%) and 90-day mortality was 2.2% (95% CI 1.2-3.4%, random-effects model; I(2) = 59.8%). CONCLUSIONS Prognostic CPRs efficiently identify PE patients at a low risk of mortality. Before implementing prognostic CPRs in the routine care of PE patients, well-designed management studies are warranted.
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Affiliation(s)
- A Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical Medicine, University of Insubria, Varese, Italy.
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Ozsu S, Abul Y, Yilmaz I, Ozsu A, Oztuna F, Bulbul Y, Ozlu T. Prognostic significance of PaO2/PaCO2 ratio in normotensive patients with pulmonary embolism. CLINICAL RESPIRATORY JOURNAL 2011; 6:104-11. [DOI: 10.1111/j.1752-699x.2011.00253.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Coutance G, Cauderlier E, Ehtisham J, Hamon M, Hamon M. The prognostic value of markers of right ventricular dysfunction in pulmonary embolism: a meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R103. [PMID: 21443777 PMCID: PMC3219376 DOI: 10.1186/cc10119] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 12/16/2010] [Accepted: 03/28/2011] [Indexed: 11/10/2022]
Abstract
Introduction In pulmonary embolism (PE) without hemodynamic compromise, the prognostic value of right ventricular (RV) dysfunction as measured by echocardiography, computed tomography (CT) or biological (natriuretic peptides) markers has only been assessed in small studies. Methods Databases were searched using the combined medical subject headings for right ventricular dysfunction or right ventricular dilatation with the exploded term acute pulmonary embolism. This retrieved 8 echocardiographic marker based studies (n = 1249), three CT marker based studies (n = 503) and 7 natriuretic peptide based studies (n = 582). A meta-analysis of these data was performed with the primary endpoint of mortality within three months after pulmonary embolism, and a secondary endpoint of overall mortality and morbidity by pulmonary embolism. Results Patients with PE without hemodynamic compromise on admission and the presence of RV dysfunction determined by echocardiography and biological markers were associated with increased short-term mortality (odds ratio (OR) ECHO = 2.36; 95% confidence interval (CI): 1.3-43; OR BNP = 7.7; 95% CI: 2.9-20) while CT was not (ORCT = 1.54-95% CI: 0.7-3.4). However, corresponding pooled negative and positive likelihood ratios independent of death rates were unsatisfactory for clinical usefulness in risk stratification. Conclusions The presence of echocardiographic RV dysfunction or elevated natriuretic peptides is associated with short-term mortality in patients with pulmonary embolism without hemodynamic compromise. In contrast, the prognostic value of RV dilation on CT has yet to be validated in this population. As indicated both by positive and negative likelihood ratios the current prognostic value in clinical practice remains very limited.
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Affiliation(s)
- Guillaume Coutance
- Cardiologie, Centre Hospitalier Universitaire de Caen, Avenue Côte de Nacre, 14033 Caen, Normandy, France
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Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1485] [Impact Index Per Article: 114.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.
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Moores L, Aujesky D, Jiménez D, Díaz G, Gómez V, Martí D, Briongos S, Yusen R. Pulmonary Embolism Severity Index and troponin testing for the selection of low-risk patients with acute symptomatic pulmonary embolism. J Thromb Haemost 2010; 8:517-22. [PMID: 20025646 DOI: 10.1111/j.1538-7836.2009.03725.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The combination of the Pulmonary Embolism Severity Index (PESI) and troponin testing could help physicians identify appropriate patients with acute pulmonary embolism (PE) for early hospital discharge. METHODS This prospective cohort study included a total of 567 patients from a single center registry with objectively confirmed acute symptomatic PE. On the basis of the PESI, each patient was classified into one of five classes (I-V). At the time of hospital admission, patients had troponin I (cTnI) levels measured. The endpoint of the study was all-cause mortality within 30 days after diagnosis. We calculated the mortality rates in four patient groups: group 1, PESI class I-II plus cTnI < 0.1 ng mL(-1); group 2, PESI classes III-V plus cTnI < 0.1 ng mL(-1); group 3, PESI classes I-II plus cTnI > or = 0.1 ng mL(-1); and group 4, PESI classes III-V plus cTnI > or = 0.1 ng mL(-1). RESULTS The study cohort had a 30-day mortality of 10% [95% confidence interval (CI), 7.6-12.5%]. Mortality rates in the four groups were 1.3%, 14.2%, 0% and 15.4%, respectively. Compared with non-elevated cTnl, the low-risk PESI had a higher negative predictive value (NPV) (98.9% vs. 90.8%) and negative likelihood ratio (NLR) (0.1 vs. 0.9) for predicting mortality. The addition of non-elevated cTnI to low-risk PESI did not improve the NPV or the NLR compared with either test alone. CONCLUSIONS Compared with cTnl testing, PESI classification more accurately identified patients with PE who are at low risk of all-cause death within 30 days of presentation.
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Affiliation(s)
- L Moores
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD, USA
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Rendina D, De Bonis S, Gallotta G, Piedimonte V, Mossetti G, De Filippo G, Farina F, Vargas G, Barbella MR, Postiglione A, Strazzullo P. Clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with central and non-massive pulmonary embolism. Intern Emerg Med 2010; 5:53-9. [PMID: 19937481 DOI: 10.1007/s11739-009-0330-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Accepted: 10/19/2009] [Indexed: 11/27/2022]
Abstract
Right ventricular dysfunction during acute pulmonary embolism (PE) predisposes to hemodynamic instability and cardiogenic shock. Aim of this case-control study was to determine the clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with acute PE involving the main or segmental pulmonary arteries (central PE) and without hemodynamic instability on admission to the Emergency Department (ED) (non-massive PE). From January 1, 2002 to December 31, 2005, 211 patients with central PE were admitted to the Department of Emergency Medicine of the "Antonio Cardarelli" Hospital (Naples, Italy). One hundred eighteen of them had echocardiographic evidence of right ventricular dysfunction on admission to the ED. A history of type 2 diabetes mellitus and chronic obstructive pulmonary disease were significantly associated with an increased risk of this PE-related complication. Compared to patients without right ventricular dysfunction, those with right ventricular dysfunction showed higher levels of markers of cardiac damage, and a significant impairment of respiratory function. Echocardiographic evidence of right ventricular dysfunction on admission to the ED was significantly associated with the occurrence of hemodynamic instability and cardiogenic shock during the PE clinical course. The study results indicate that a history of type 2 diabetes mellitus and chronic obstructive pulmonary disease are significantly associated with the occurrence of right ventricular dysfunction in patients with non-massive and central PE independent of age, gender and other historical and clinical variables detectable on admission to the ED.
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Affiliation(s)
- Domenico Rendina
- Department of Clinical and Experimental Medicine, Federico II University Medical School, via S. Pansini, 5, 80131, Naples, Italy.
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