Right ventricle dysfunction and pulmonary hypertension in hemodynamically stable pulmonary embolism

[Diagnostic Algorithm and Screening of Pulmonary Hypertension]

The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.

Relationship Between Soluble ST2 Level and Chronic Thromboembolic Pulmonary Hypertension (CTEPH) in Acute Pulmonary Embolism (PE) Patients

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease characterized by right heart failure following recurrent pulmonary embolism (PE). It is important to know the predictors of the development of CTEPH after PE as it is a treatable cause of pulmonary arterial hypertension. Soluble ST2 is a biomarker closely associated with heart failure and the inflammatory process. The aim of this study was to investigate the relationship between sST2 level and the development of CTEPH in patients with PE.

METHODOLOGY

Baseline characteristics, electrocardiographic findings, laboratory findings, transthoracic echocardiography (TTE) findings, location, and extent of involvement in CT pulmonary angiography were recorded in 100 patients with acute PE included in our prospective study. Treatment modalities and treatment durations were followed. Ventilation-perfusion scintigraphy was performed in patients with a systolic pulmonary artery pressure (sPAP) of 35 mmHg or more on TTE and residual thrombus on CT pulmonary angiography after at least three months of anticoagulant use. In the case of findings compatible with CTEPH in these examinations, patients were diagnosed with CTEPH by right heart catheterization. The sST2 levels obtained from all patients at admission were evaluated between the groups of patients with and without CTEPH.

RESULTS

CTEPH was observed in 11 of the 100 patients who participated in the trial, with a median follow-up of 284 ± 60 days. The mean age of the 11 patients with CTEPH was 67 ± 10 years; five were males and six were females. The mean age of 89 patients without CTEPH was 65 ± 18 years, 36 were males and 53 were females. The sST2 values of the group with CTEPH were found to be statistically significantly higher than those of patients without CTEPH [193.7 (184.3-244.7) vs 58.6 (29.5-122.9) p=0.020]. This receiver operating characteristic (ROC) curve shows that the optimal cutoff point of sST2 levels in the prediction of CTEPH was > 157.4 with specificity of 83.7% and sensitivity of 81.8% (area under the curve = 0.783; 95% CI, 1.005-1.027; p < 0.001).

CONCLUSION

In acute PE patients, sST2 levels may be a useful biomarker to predict the development of CTEPH.

ERS statement on chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.

Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism

OBJECTIVE

This study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated.

MATERIALS AND METHODS

In the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction.

RESULTS

PAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001).

CONCLUSIONS

PAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.

Determinants and Management of the Post-Pulmonary Embolism Syndrome

Acute pulmonary embolism (PE) is not only a serious and potentially life-threatening disease in the acute phase, in recent years it has become evident that it may also have a major impact on a patient's daily life in the long run. Persistent dyspnea and impaired functional status are common, occurring in up to 50% of PE survivors, and have been termed the post-PE syndrome (PPES). Chronic thromboembolic pulmonary hypertension is the most feared cause of post-PE dyspnea. When pulmonary hypertension is ruled out, cardiopulmonary exercise testing can play a central role in investigating the potential causes of persistent symptoms, including chronic thromboembolic pulmonary disease or other cardiopulmonary conditions. Alternatively, it is important to realize that post-PE cardiac impairment or post-PE functional limitations, including deconditioning, are present in a large proportion of patients. Health-related quality of life is strongly influenced by PPES, which emphasizes the importance of persistent limitations after an episode of acute PE. In this review, physiological determinants and the diagnostic management of persistent dyspnea after acute PE are elucidated.

MR-proADM and MR-proANP levels in patients with acute pulmonary embolism

BACKGROUND

The aim of this study was to determine levels of Mid-regional Pro-adrenomedullin (MR-proADM) and Mid-regional Pro-atrial Natriuretic Peptide (MR-proANP) in patients with acute pulmonary embolism (PE), the relationship between these parameters and the risk classification in addition to determining the relationship between 1and 3month mortality.

METHODS

82 PE patients and 50 healthy control subjects were included in the study. Blood samples for Mr-proANP and Mr-proADM were obtained from the subjects prior to the treatment. Risk stratification was determined according to sPESI (Simplified Pulmonary Embolism Severity Index). Following these initial measurements, cases with PE were assessed in terms of all causative and PE related mortalities.

RESULTS

The mean serum Mr-proANP and Mr-proADM levels in acute PE patients were found to be statistically higher compared to the control group (p < 0.001, p < 0.01; respectively) and statistically significantly higher in high-risk patients than low-risk patients (p < 0.01, p < 0.05; respectively). No statistical difference was determined in high-risk patients in case of sPESI compared to low-risk patients while hospital mortality rates were higher. It was determined that the hospital mortality rate in cases with Mr-proANP ≥ 123.30 pmol/L and the total 3-month mortality rate in cases with Mr-proADM ≥ 152.2 pg/mL showed a statistically significant increase.

CONCLUSIONS

This study showed that Mr-proANP and MRproADM may be an important biochemical marker for determining high-risk cases and predicting the mortality in PE patients and we believe that these results should be supported by further and extensive studies.

Endocan as a marker of disease severity in pulmonary thromboembolism

INTRODUCTION

The aim of this study is to determine the serum endocan levels in patients with pulmonary thromboembolism (PTE) and investigate whether a relationship exists between serum endocan levels and the disease severity.

MATERIALS AND METHODS

The study included 85 patients with acute PTE and 40 healthy control subjects. The patients with PTE were divided into three groups at admission as "high-risk", "intermediate-risk" and "low-risk", considering the guidelines of the European Society of Cardiology. Serum endocan levels in all participants' blood samples were measured.

RESULTS

The mean serum endocan levels were significantly higher in the PTE group, compared to the control subjects (P < 0.001). Serum endocan levels were significantly higher in the "high-risk" group when compared with patients in the "low-risk" and "intermediate-risk" groups (P < 0.001 and P < 0.01 respectively). Similarly, serum endocan levels were higher in the "intermediate-risk" group compared to those in the "low-risk" group (P < 0.001). There was a negative correlation between serum endocan levels and partial oxygen pressure (r = -0.262, P = 0.016), whereas a positive correlation was found between the serum endocan levels and systolic pulmonary arterial pressure (r = 0.296, P = 0.006). Additionally, endocan had an area under the curve in the receiver operating characteristic curve of 0.837 (0.768-0.907; 95% CI; P < 0.001) and cut-off value was 194.5 pg/mL (sensitivity 80%, specificity 72.5%).

CONCLUSION

Serum endocan levels were higher and related to the severity of the disease in PTE patients. Additionally, endocan could be an indicator to be used in the diagnosis of PTE and in the prediction of the disease severity.

Chronic thromboembolic pulmonary hypertension (CTEPH): what do we know about it? A comprehensive review of the literature

: Chronic thromboembolic disease (CTED), especially when associated with pulmonary hypertension (CTEPH), is a fearsome and under-diagnosed but potentially curable complication of pulmonary embolism, thanks to recent therapeutic options. Aspecific symptoms and signs make its diagnosis challenging, requiring clinicians to be ready to suspect its presence in patients with dyspnea of unknown origin or persistent symptoms after acute pulmonary embolism. The aim of this review is to provide an update to the general practitioner or the specialist physician on the state of the art regarding the epidemiology, pathophysiology and clinical management of chronic thromboembolic syndromes.

From Acute to Chronic Thromboembolic Disease

After achievement of adequate anticoagulation, the natural history of acute pulmonary emboli ranges from near total resolution of vascular perfusion to long-term persistence of hemodynamically consequential residual perfusion defects. The persistence of perfusion defects is necessary, but not sufficient, for the development of chronic thromboembolic pulmonary hypertension (CTEPH). Approximately 30% of patients have persistent defects after 6 months of anticoagulation, but only 10% of those with persistent defects subsequently develop CTEPH. A number of clinical risk factors including increasing age, delay in anticoagulation from symptom onset, and the size of the initial thrombus have been associated with the persistence of perfusion defects. Likewise, a number of cellular and molecular pathways have been implicated in the failure of thrombus resolution, including impaired fibrinolysis, altered fibrinogen structure and function, increased local or systemic inflammation, and remodeling of the embolic material by neovascularization. Treatment with fibrinolytic agents at the time of initial presentation has not clearly improved the frequency or degree of recovery of pulmonary vascular perfusion. A better understanding of the interplay between clinical risk factors and pathogenic mechanisms may enhance the ability to prevent and treat CTEPH in the future.

Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a contemporary view of the published literature

The incidence of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is relevant for management decisions but is currently unknown.We performed a meta-analysis of studies including consecutive PE patients followed for CTEPH. Study cohorts were predefined as "all comers", "survivors" or "survivors without major comorbidities". CTEPH incidences were calculated using random effects models.We selected 16 studies totalling 4047 PE patients who were mostly followed up for >2-years. In 1186 all comers (two studies), the pooled CTEPH incidence was 0.56% (95% CI 0.1-1.0). In 999 survivors (four studies) CTEPH incidence was 3.2% (95% CI 2.0-4.4). In 1775 survivors without major comorbidities (nine studies), CTEPH incidence was 2.8% (95% CI 1.5-4.1). Both recurrent venous thromboembolism and unprovoked PE were significantly associated with a higher risk of CTEPH, with odds ratios of 3.2 (95% CI 1.7-5.9) and 4.1 (95% CI 2.1-8.2) respectively. The pooled CTEPH incidence in 12 studies that did not use right heart catheterisation as the diagnostic standard was 6.3% (95% CI 4.1-8.4).The 0.56% incidence in the all-comer group probably provides the best reflection of the incidence of CTEPH after PE on the population level. The ∼3% incidences in the survivor categories may be more relevant for daily clinical practice. Studies that assessed CTEPH diagnosis by tests other than right heart catheterisation provide overestimated CTEPH incidences.

Platelet-to-lymphocyte ratio as a novel marker of in-hospital and long-term adverse outcomes among patients with acute pulmonary embolism: A single center large-scale study

BACKGROUND

The interaction of platelets with leukocytes is a well-known process both in progression and prognosis of acute pulmonary embolism (PE). Recently, platelet to lymphocyte ratio (PLR) is emerged as an indirect inflammatory indicator which was shown to be associated with adverse cardiovascular events in various clinical conditions, including acute PE. However, the long-term prognostic value of PLR in acute PE has not been investigated thoroughly. Therefore, we aimed to assess the impact of PLR on both in-hospital and long-term adverse outcomes in acute PE.

METHODS

A total of 459 patients with definite diagnosis of acute PE between January 2009 and January 2016 were enrolled. On admission, blood sampling to calculate PLR and detailed clinical data were obtained. Patients were divided into tertiles according to the admission PLR levels. Simplified PE severity index (sPESI) score and computerized tomography (CT) based pulmonary artery obstruction index were calculated for each patient.

RESULTS

Mean sPESI score of the study population was 1.6. A total of 34 patients (7.4%) died during index hospitalization. At median 28.8months follow-up, all-cause mortality was observed in 81 patients (1.9%). Patients in the highest tertile of PLR revealed a higher rate of in-hospital adverse events including cardiogenic shock, the necessity for thrombolytic therapy and in-hospital mortality as well as long-term all-cause mortality. In multivariate analysis, the PLR was found to be a significant predictor of both in-hospital adverse events (OR: 1.588, 95% CI:1.116-2.154, p=0.004) and long-term all-cause mortality (OR:1.746, 95% CI:1.211-2.865, p=0.001).

CONCLUSIONS

The PLR, as a simple, inexpensive and available marker of inflammatory and prothrombotic status, seemed to be a novel predictor of in-hospital and long-term adverse outcomes in patients with acute PE.

Persistent right ventricular dysfunction, functional capacity limitation, exercise intolerance, and quality of life impairment following pulmonary embolism: Systematic review with meta-analysis

Long-term right ventricular (RV) function, functional capacity, exercise capacity, and quality of life following pulmonary embolism (PE), and the impact of thrombolysis, are unclear. A systematic review of studies that evaluated these outcomes with ⩾ 3-month mean follow-up after PE diagnosis was performed. For each outcome, random effects meta-analyses were performed. Twenty-six studies (3671 patients) with 18-month median follow-up were included. The pooled prevalence of RV dysfunction was 18.1%. Patients treated with thrombolysis had a lower, but not statistically significant, risk of RV dysfunction versus those treated with anticoagulation (odds ratio: 0.51, 95% CI: 0.24 to 1.13, p=0.10). Pooled prevalence of at least mild functional impairment (NYHA II–IV) was 33.2%, and at least moderate functional impairment (NYHA III–IV) was 11.3%. Patients treated with thrombolysis had a lower, but not statistically significant, risk of at least moderate functional impairment versus those treated with anticoagulation (odds ratio: 0.48, 95% CI: 0.15 to 1.49, p=0.20). Pooled 6-minute walk distance was 415 m (95% CI: 372 to 458 m), SF-36 Physical Component Score was 44.8 (95% CI: 43 to 46), and Pulmonary Embolism Quality of Life (QoL) Questionnaire total score was 9.1. Main limitations included heterogeneity among studies for many outcomes, variation in the completeness of data reported, and inclusion of data from non-randomized, non-controlled, and retrospective studies. Persistent RV dysfunction, impaired functional status, diminished exercise capacity, and reduced QoL are common in PE survivors. The effect of thrombolysis on RV function and functional status remains unclear.

Mean platelet volume and mean platelet volume/platelet count ratio in risk stratification of pulmonary embolism

BACKGROUND AND OBJECTIVE

Recently, some of the hemogram parameters were reported to predict early death in acute pulmonary embolism (PE). The aim of this study was to investigate the role of mean platelet volume (MPV) and MPV/platelet count ratio (MPV/P), WBC and red cell distribution width (RDW) in risk stratification of patients with acute PE.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients with acute PE admitted to the Emergency Department. In addition to the clinical evaluation, the hemogram parameters were measured on admission.

RESULTS

A total of 152 patients were included. Patients with RV dysfunction had significantly higher MPV levels and MPV/P than patients without RV dysfunction. Receiver operating characteristic curve analysis revealed that a MPV cut-off of 7.85fL provided a sensitivity of 53.3% and a specificity of 68.5%, and a MPV/P cut-off of 0.0339fL/(10(9)/L) provided a sensitivity of 69.6% and a specificity of 65% for the prediction of RV dysfunction. There was a positive correlation between MPV and systolic pulmonary artery pressure (SPAP) and between MPV and RV diameter. There was a positive correlation between MPV/P and SPAP and between MPV/P and RV diameter. The low-risk PE group had lower MPV and MPV/P than the massive PE and submassive PE groups.

CONCLUSIONS

MPV and MPV/P were found to be associated with RV dysfunction and clinical severity in acute PE. Low MPV and MPV/P levels may be an indicator of low risk and, high WBC levels may be an indicator of high risk in patients with acute PE. RDW levels may not reflect severity of acute PE.

Fragmented QRS Complex Predicts In-Hospital Adverse Events and Long-Term Mortality in Patients with Acute Pulmonary Embolism

BACKGROUND

Electrocardiographic (ECG) abnormalities in pulmonary embolism (PE) are increasingly reported, and mounting data have recommended that ECG plays a crucial role in the prognostic assessment of PE patient population. However, there is scarce data on the prognostic importance of fragmented QRS (fQRS) on short- and long-term outcomes in patients with PE. Therefore, we aimed to investigate the prognostic role of fQRS in predicting in-hospital and long-term adverse outcomes in PE patients.

METHODS

A total of 249 patients (155 female, 66.2%; mean age, 66.0 ± 16.0) with the diagnosis of acute PE were enrolled and followed-up during median 24.8 months.

RESULTS

Compared with the fQRS (-) patient group, patients with fQRS showed higher rates of in-hospital adverse events including cardiogenic shock, the necessity of thrombolytic therapy, and in-hospital mortality as well as long-term all-cause mortality. In Kaplan-Meier survival analysis, during follow-up, all-cause mortality occurred more frequently in the fQRS (+) group (log-rank, P = 0.002). In multivariate Cox regression analysis, adjusted with other relevant parameters, the presence of fQRS were determined as an independent predictor of in-hospital adverse events (HR: 2.743, 95% CI: 1.267-5.937, P = 0.003) and long-term all-cause mortality (HR: 3.137, 95% CI: 1.824-6.840, P = 0.001).

CONCLUSIONS

The presence of fQRS complex, as a simple and feasible ECG marker, seems to be a novel predictor of in-hospital adverse events and long-term all-cause mortality in PE patient population. This parameter may utilize the identification of patients whom at higher risk for mortality and individualization of therapy.

Predictive Value of Computed Tomography in Acute Pulmonary Embolism: Systematic Review and Meta-analysis

BACKGROUND

Many computed tomography (CT) parameters have been proposed as potential predictors of outcome in acute pulmonary embolism. We sought to summarize available evidence on the predictive value of CT severity parameters for short-term clinical outcome in pulmonary embolism.

METHODS

We searched PubMed and EMBASE through February 2014 for studies that reported on the association between CT parameters of acute pulmonary embolism severity and short-term (≤6 months) clinical outcome. Risk estimates for quantitative parameters of right ventricular (RV) dysfunction (abnormally increased RV/left ventricular [LV] diameter ratio on transverse sections and 4-chamber views), qualitative parameters of RV dysfunction (abnormal septal morphology and contrast reflux), thrombus load, and central thrombus location were derived using random effect regression analysis. Meta-regression analysis was performed to quantify and explain study heterogeneity.

RESULTS

A total of 49 studies with 13,162 patients with acute pulmonary embolism (median age of 61 years, 55.1% were women) who underwent diagnostic CT imaging were included in the analysis. An abnormally increased RV/LV diameter ratio measured on transverse sections was associated with an approximately 2.5-fold risk for all-cause mortality (pooled odds ratio [OR], 2.5; 95% confidence interval [CI], 1.8-3.5) and adverse outcome (OR, 2.3; 95% CI, 1.6-3.4) and a 5-fold risk for pulmonary embolism-related mortality (OR, 5.0; 95% CI, 2.7-9.2). Thrombus load (OR, 1.6, 95% CI, 0.7-3.9; P = .2896) and central location (OR, 1.7; 95% CI, 0.7-4.2; P = .2609) were not predictive for all-cause mortality, although both were associated with adverse clinical outcome.

CONCLUSIONS

Across all end points, the RV/LV diameter ratio on transverse CT sections has the strongest predictive value and most robust evidence base for adverse clinical outcomes in patients with acute pulmonary embolism.

Evaluation of serum endothelial cell specific molecule-1 (endocan) levels as a biomarker in patients with pulmonary thromboembolism

The aim of this study was to investigate the relationship between pulmonary thromboembolism (PTE) and serum endocan levels. The study included 46 patients with a diagnosis of PTE and control group (25 healthy individuals). Serum endocan levels in all participants' blood samples were measured. The average age of the individuals was 61.76 ± 16.39 years. There was a significant difference in the serum endocan levels between the patients and those of the control group [321.93 ng/l (111.35-2511.33) and 192.77 ng/l (118.30-309.02), respectively; P < 0.030]. The serum endocan levels in the submassive [469.41 ng/l (258.13-800.54)] and the massive PTE groups [719.18 ng/l (319.84-2511.33)] were statistically higher than those in the control group [192.77 ng/l (118.30-309.02)] (P < 0.001 and P < 0.001, respectively). In addition, there was a statistically significant difference between the serum endocan levels of the nonmassive PTE group [188.57 ng/l (111.35-685.56)] and the submassive PTE group (P < 0.01). The serum endocan levels correlated with the international normalization ratio (INR), right ventricular dilatation (RVD) and SBP (r = 0.418, P = 0.004; r = 0.659, P < 0.001; r = -0.425, P = 0.003, respectively). In conclusion, serum endocan levels can be considered a practicable biomarker to determine the severity of PTEs and follow-up thrombolytic therapy.

Venous thromboembolism increases the risk of atrial fibrillation: the Tromso study

BACKGROUND

Pulmonary embolism (PE) may trigger atrial fibrillation through increased right atrial pressure and subsequent atrial strain, but the degree of evidence is low. In this study, we wanted to investigate the impact of incident venous thromboembolism (VTE) on future risk of atrial fibrillation in a prospective population-based study.

METHODS AND RESULTS

The study included 29 974 subjects recruited from the Tromsø study (1994-1995, 2001-2002, 2007-2008). Incident VTE and atrial fibrillation events were registered from date of enrolment to end of follow-up, December 31, 2010. Cox proportional hazard regression models using age as time-scale and VTE as a time-dependent variable were used to estimate crude and multivariable hazard ratios (HRs) for atrial fibrillation with 95% confidence intervals (CIs). During 16 years of follow up, 540 (1.8%) subjects had an incident VTE event, and 1662 (5.54%) were diagnosed with atrial fibrillation. Among those with VTE, 50 (9.3%) developed subsequent atrial fibrillation. Patients with VTE had 63% higher risk of atrial fibrillation compared to subjects without VTE (multivariable-adjusted HR: 1.63, 95% CI: 1.22 to 2.17). The risk of atrial fibrillation was particularly high during the first 6 months after the VTE event (HR 4.00, 95% CI: 2.21 to 7.25) and among those with PE (HR 1.78, 95% CI: 1.13 to 2.80).

CONCLUSIONS

We found that incident VTE was associated with future risk of atrial fibrillation. Our findings support the hypothesis that PE may lead to cardiac dysfunctions that, in turn, could trigger atrial fibrillation.

Chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.

Long-term outcome of patients with persistent vascular obstruction on computed tomography pulmonary angiography 6 months after acute pulmonary embolism

BACKGROUND

The incidence and clinical significance of pulmonary residual thrombosis 6 months after an acute pulmonary embolism (PE) are still not well-known.

PURPOSE

To evaluate the association between residual vascular obstruction and the risk of venous thromboembolism (VTE) recurrence or death.

MATERIAL AND METHODS

Computed tomography pulmonary angiography (CTPA) was repeated in 97 consecutive patients 6 months after an acute episode of hemodynamically stable pulmonary embolism. We assessed the long-term consequences of residual thrombosis on vital status and incidence of recurrent VTE.

RESULTS

Six patients were lost for follow-up. The remaining 91 patients were classified according to the presence (Group 1: 18 cases) or absence (Group 2: 73 cases) of residual pulmonary vascular obstruction. After a mean ± SD of 2.91 ± 0.99 years, there were eight (8.8%) deaths and 11 (12.1%) VTE recurrences. Groups 1 and 2 did not differ in the incidence of death or VTE recurrence.

CONCLUSION

Persistent pulmonary vascular obstruction on 6-month CTPA did not predict long-term adverse outcome events.

Helical computerized tomography and NT-proBNP for screening of right ventricular overload on admission and at long term follow-up of acute pulmonary embolism

Background

Right ventricular dysfunction (RVD) in acute pulmonary embolism (APE) can be assessed with helical computerized tomography (CT) and transthoracic echocardiography (TTE). Signs of RVD and elevated natriuretic peptides like NT-proBNP and cardiac troponin (TnT) are associated with increased risk of mortality. However, the prognostic role of both initial diagnostic strategy and the use of NT-proBNP and TnT for screening for long-term probability of RVD remains unknown. The aim of the study was to determine the role of helical CT and NT-proBNP in detection of RVD in the acute phase. In addition, the value of NT-proBNP for ruling out RVD at long-term follow-up was assessed.

Methods

Sixty-three non-high risk APE patients were studied. RVD was assessed at admission in the emergency department by CT and TTE, and both NT-proBNP and TnT samples were taken. These, excepting CT, were repeated seven months later.

Results

At admission RVD was detected by CT in 37 (59 %) patients. RVD in CT correlated strongly with RVD in TTE (p < 0.0001). NT-proBNP was elevated (≥ 350 ng/l) in 32 (86 %) patients with RVD but in only seven (27 %) patients without RVD (p < 0.0001). All the patients survived until the 7-month follow-up. TTE showed persistent RVD in 6 of 63 (10 %) patients who all had RVD in CT at admission. All of them had elevated NT-proBNP levels in the follow-up compared with 5 (9 %) of patients without RVD (p < 0.0001).

Conclusions

TTE does not confer further benefit when helical CT is used for screening for RVD in non-high risk APE. All the patients who were found to have RVD in TTE at seven months follow-up had had RVD in the acute phase CT as well. Thus, patients without RVD in diagnostic CT do not seem to require further routine follow-up to screen for RVD later. On the other hand, persistent RVD and thus need for TTE control can be ruled out by assessment of NT-proBNP at follow-up. A follow-up protocol based on these findings is suggested.

Normalization of negative T-wave on electrocardiography and right ventricular dysfunction in patients with an acute pulmonary embolism

BACKGROUND/AIMS

Right ventricular dysfunction (RVD) is associated with poor prognosis in patients with acute pulmonary embolism (APE). Echocardiography and computed tomography (CT)-angiography may be difficult to perform in a serial follow up, unlike electrocardiography (ECG). Many ECG findings specific for APE have been reported, and many studies have found that negative T-waves (NTW) in precordial leads are most frequently observed in patients with APE. We analyzed serial changes in precordial NTW to detect RVD and predict the recovery of RVD in patients with APE.

METHODS

We examined 81 consecutive patients diagnosed with APE using CT-angiography or echocardiography. ECG, transthoracic echocardiography, and laboratory tests were performed within 24 hours of admission, and daily ECG follow-up was performed. Precordial NTWs were defined by the new development of pointed and symmetrical inverted T-waves in at least three leads. Recovery of NTW was defined as flattening or upright inverted T-waves in more than two leads.

RESULTS

Of the 81 patients with APE, 52 (64%) had RVD according to echocardiography. Among the patients with RVD, 33 (63%) showed precordial NTW. The multivariate logistic regression analysis revealed that NTW was the strongest independent predictor for RVD (odds ratio, 22.8; 95% confidence interval, 2.4 to 221.4; p = 0.007). Time to normalization of NTW was associated with improvement of RVD on echocardiography (r = 0.84, p < 0.01).

CONCLUSIONS

Precordial NTW was a reliable finding to identify RVD in patients with APE. Improvements in RVD can be predicted by normalizing precordial NTW.

Clinical implications of right ventricular dysfunction in patients with acute symptomatic pulmonary embolism: short- and long-term clinical outcomes

PURPOSE

Right ventricular dysfunction (RVD) has been found to have a negative impact on the short-term prognosis of patients with pulmonary embolism (PE). However, the long-term prognosis of such patients has not been well defined. We evaluated the effect of RVD on short- and long-term mortality in Korean patients with PE.

MATERIALS AND METHODS

We retrospectively assessed 180 patients with PE who underwent transthoracic echocardiography to evaluate RVD between January 2004 and December 2008. Patients were categorized as hemodynamically stable without RVD (stable without RVD, n = 70), hemodynamically stable with RVD (stable with RVD, n = 74), or hemodynamically unstable with RVD (unstable with RVD, n = 36). The clinical courses of all patients were followed up in-hospital and after discharge.

RESULTS

Nineteen patients (10.5%) died during hospitalization, with the unstable with RVD group showing the highest rate of in-hospital mortality (27.8%, P < .05) and PE-related deaths (16.7%, P < .05), but no difference in these parameters was noted between the other 2 groups. Multivariate analysis showed that older age and hemodynamic instability were independent risk factors for poor in-hospital outcomes. Eleven patients died after discharge. Multivariate analysis showed that older age, immobilization, and malignancy were independent predictors of long-term mortality.

CONCLUSION

Right ventricular dysfunction without hemodynamic instability was not associated with short- or long-term mortality of patients with PE.

Subjective assessment of right ventricle enlargement from computed tomography pulmonary angiography images

To retrospectively evaluate prognostic accuracy of subjective assessment of right ventricle (RV) enlargement on CT pulmonary angiography (CTPA) images in comparison with objective measures of RV enlargement in patients with acute pulmonary embolism (PE). For 200 consecutive patients with acute PE, two readers blinded to patient outcomes subjectively determined whether the maximum RV diameter was greater than that of the left ventricle (LV) using axial CTPA images. For the objective measurements, RV/LV diameter ratios were calculated using axial images and 4-chamber reformatted images. For all assessments, sensitivities and specificities for predicting PE-related death within 30-days and a composite outcome including PE-related death or the need for intensive therapies were compared. The agreement between two readers was 91.5% (kappa = 0.83) and all other assessments had pair-wise agreement over 75% (kappa = 0.53-0.72). There was no significant difference in sensitivity between the subjective and objective methods for predicting both outcomes. The specificity for subjective RV enlargement (55.4-67.7%) was significantly higher than objective measures (45.8-53.1%), except for the 4-chamber views where, for one reader, the specificity of the subjective evaluation was higher but did not reach statistical significance. Complex measurements of RV/LV diameter ratios may not be needed to maximize the prognostic value from CTPA. The radiologist who interprets the CTPA images should report RV enlargement when the RV diameter subjectively appears larger than the LV.

Electrocardiogram score predicts severity of pulmonary embolism in hemodynamically stable patients

BACKGROUND

Risk stratification of patients with pulmonary embolism (PE) is essential to guide therapy. The presence of right ventricle dysfunction (RVD) and the anatomic extent of PE have been suggested to predict clinical course. The aim of this study was to assess the ability of an electrocardiogram (ECG) scoring system to predict RVD or the clot load score in normotensive patients with PE.

METHODS

Consecutive patients presenting to the emergency room with PE and hemodynamic stability were prospectively included. ECG, echocardiography and computed tomography pulmonary angiography (CTPA) were performed on all patients.

RESULTS

A total of 103 patients were studied. ECG score correlated significantly with the clot load score (r = 0.41, 95% confidence interval [CI]: 0.22-0.57, P < 0.001), systolic pulmonary artery pressure (r= 0.31, 95% CI: 0.09-0.49, P = 0.006), pulmonary artery diameter (r = 0.28, 95% CI: 0.07-0.47, P = 0.011) and right ventricle to left ventricle ratio, both measured with echocardiography (r = 0.42, 95% CI: 0.22-0.57, P < 0.001) and with CTPA (r= 0.36, 95% CI: 0.13-0.56, P = 0.004). Area under the receiver operating characteristic curve for detecting RVD was 0.82 (95% CI: 0.72-0.89). Interobserver agreement regarding ECG score was substantial (κ = 0.80).

CONCLUSIONS

ECG score correlates with the severity of PE in hemodynamically stable patients. It is potentially useful for risk-stratification strategies in this setting.

[Troponin-I in hemodynamically-stable pulmonary embolism: correlation with echocardiography and computed tomography angiography]

BACKGROUND

Troponin-I (TnI) is a marker of severe pulmonary thromboembolism (PTE) in unselected patients. There are few articles that assess its usefulness in hemodynamically-stable patients.

OBJECTIVES

To assess the correlation between TnI levels and both echocardiographic/radiologic signs of right ventricle (RV) dysfunction or pulmonary hypertension (PH), and the severity of the pulmonary vascular obstruction.

METHODS

We selected patients from a prospective cohort of 103 consecutive patients with PTE and systolic arterial pressure ≥ 90 mmHg. Computed tomography pulmonary angiography (CTPA) and echocardiography were performed in all patients. We performed a post hoc study, analyzing the 68 cases in which TnI was measured, at the discretion of the emergency room physician.

RESULTS

Patients included had a median age of 74 years and 50% were male. The patients with elevated TnI had a differentiated clinical profile, suggestive of more severe PTE. There was a significant correlation between TnI levels and systolic pulmonary artery pressure (r=0.46, P<.001), the CTPA-measured pulmonary artery diameter (r=0.48, P<.001), the CTPA-measured RV diameter (r=0.47, P=.001) and the pulmonary vascular obstruction index (r=0.39, P=.001).

CONCLUSION

The higher levels of TnI in patients with hemodynamically stable PTE predicts the existence of more severe PE in hemodynamically-stable patients. This biomarker could be used in the clinical practice to select those patients who might require more intensive monitoring or additional complementary studies.