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

Immediate cardiopulmonary responses to consecutive pulmonary embolism: a randomized, controlled, experimental study

BACKGROUND

Acute pulmonary embolism (PE) induces ventilation-perfusion mismatch and hypoxia and increases pulmonary pressure and right ventricular (RV) afterload, entailing potentially fatal RV failure within a short timeframe. Cardiopulmonary factors may respond differently to increased clot burden. We aimed to elucidate immediate cardiopulmonary responses during successive PE episodes in a porcine model.

METHODS

This was a randomized, controlled, blinded study of repeated measurements. Twelve pigs were randomly assigned to receive sham procedures or consecutive PEs every 15 min until doubling of mean pulmonary pressure. Cardiopulmonary assessments were conducted at 1, 2, 5, and 13 min after each PE using pressure-volume loops, invasive pressures, and arterial and mixed venous blood gas analyses. ANOVA and mixed-model statistical analyses were applied.

RESULTS

Pulmonary pressures increased after the initial PE administration (p < 0.0001), with a higher pulmonary pressure change compared to pressure change observed after the following PEs. Conversely, RV arterial elastance and pulmonary vascular resistance was not increased after the first PE, but after three PEs an increase was observed (p = 0.0103 and p = 0.0015, respectively). RV dilatation occurred following initial PEs, while RV ejection fraction declined after the third PE (p = 0.004). RV coupling exhibited a decreasing trend from the first PE (p = 0.095), despite increased mechanical work (p = 0.003). Ventilatory variables displayed more incremental changes with successive PEs.

CONCLUSION

In an experimental model of consecutive PE, RV afterload elevation and dysfunction manifested after the third PE, in contrast to pulmonary pressure that increased after the first PE. Ventilatory variables exhibited a more direct association with clot burden.

Association between severity of pulmonary embolism and health-related quality of life

BACKGROUND

Health-related quality of life (QoL) impairment is common after pulmonary embolism (PE). Whether severity of the initial PE has an impact on QoL is unknown.

OBJECTIVE

To evaluate the association between severity of PE and QoL over time.

METHODS

We prospectively assessed PE-specific QoL using the Pulmonary Embolism Quality of Life (PEmb-QoL; lower scores indicate better QoL) and generic QoL using the Short Form 36 (SF-36; higher scores indicate better QoL) questionnaire at baseline, 3, and 12 months in older patients with acute PE. We examined whether QoL differed by PE severity based on hemodynamic status, simplified Pulmonary Embolism Severity Index (sPESI), right-ventricular function, and high-sensitivity (hs)-troponin T in mixed-effects models, adjusting for known QoL predictors after PE.

RESULTS

Among 546 patients with PE (median age 74 years), severe vs. non-severe PE based on the sPESI was associated with a worse PE-specific (adjusted mean PEmb-QoL score difference of 6.1 [95%CI 2.4;9.8] at baseline, 7.6 [95%CI 4.0;11.3] at 3 months, and 6.7 [95%CI 2.9;10.4] at 12 months) and physical generic QoL (adjusted mean SF-36 Physical Component Summary score difference -3.8 [95%CI -5.5;-2.1] at baseline; -4.8 [95%CI -6.4;-3.1] at 3 months; -4.1 [95%CI -5.8;-2.3] at 12 months). Elevated troponin was also associated with lower PE-specific QoL at 3 and physical generic QoL at 3 and 12 months. QoL did not differ by hemodynamic status or right-ventricular function.

CONCLUSION

Severe PE based on the sPESI was consistently associated with worse PE-specific and physical generic QoL over time as compared to non-severe PE.

The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism

AIMS

Right ventricular (RV) failure causes death from acute pulmonary embolism (PE), due to a mismatch between RV systolic function and increased RV afterload. We hypothesized that an echocardiographic ratio of this mismatch [RV systolic function by tricuspid annular plane systolic excursion (TAPSE) divided by pulmonary arterial systolic pressure (PASP)] would predict adverse outcomes better than each measurement individually, and would be useful for risk stratification in intermediate-risk PE.

METHODS AND RESULTS

This was a retrospective analysis of a single academic centre Pulmonary Embolism Response Team registry from 2012 to 2019. All patients with confirmed PE and a formal transthoracic echocardiogram performed within 2 days were included. All echocardiograms were analysed by an observer blinded to the outcome. The primary endpoint was a 7-day composite outcome of death or haemodynamic deterioration. Secondary outcomes were 7- and 30-day all-cause mortality. A total of 627 patients were included; 135 met the primary composite outcome. In univariate analysis, the TAPSE/PASP was associated with our primary outcome [odds ratio = 0.028, 95% confidence interval (CI) 0.010-0.087; P < 0.0001], which was significantly better than either TAPSE or PASP alone (P = 0.017 and P < 0.0001, respectively). A TAPSE/PASP cut-off value of 0.4 was identified as the optimal value for predicting adverse outcome in PE. TAPSE/PASP predicted both 7- and 30-day all-cause mortality, while TAPSE and PASP did not.

CONCLUSION

A combined echocardiographic ratio of RV function to afterload is superior in prediction of adverse outcome in acute intermediate-risk PE. This ratio may improve risk stratification and identification of the patients that will suffer short-term deterioration after intermediate-risk PE.

Differences in clinical and echocardiographic variables and mortality predictors among older patients with pulmonary embolism

BACKGROUND

An increase in short-term mortality can be found among older patients with hemodynamically stable acute pulmonary embolism (APE) who have signs of right ventricular (RV) dysfunction.

AIMS

This study was designed to assess whether any difference exists among clinical, laboratory, electrocardiography and echocardiography parameters between older and younger patients diagnosed with APE.

METHODS

The study sample included a total of 635 patients with confirmed APE who were divided into two groups of older (65 years and older) and younger (younger than 65 years) individuals. Comparisons were performed between these groups in terms of clinical, predisposing factors and laboratory, electrocardiographic and echocardiographic parameters.

RESULTS

Analyses of 295 (46.4%) older and 340 (53.6%) younger patients diagnosed with APE were performed. Female sex, Pulmonary Embolism Severity Index score and baseline creatinine levels were higher in the older group. Also, the frequency of atrial fibrillation, RV outflow tract parasternal long-axis proximal diameter, RV end-diastolic diameter (RV-EDD) basal (apical four-chamber) and RV systolic pressure were significantly greater in older patients with APE. A total of 30 (4.7%) deaths were observed during the in-hospital period [21 (7.1%) older vs 9 (2.6%) younger patients; p < 0.01]. In the multivariate logistic regression analysis, age, white blood cell count (WBC), left ventricular ejection fraction (LVEF), RV-EDD basal and tricuspid annular plane systolic excursion (TAPSE) of less than 16 mm were found to be independently associated with in-hospital mortality.

CONCLUSION

Older patients might experience greater rates of RV dilatation, RV dysfunction and atrial fibrillation during APE. In addition to age; elevated WBC, low LVEF, increased RV-EDD basal and TAPSE of less than 16 mm were independent predictors of mortality among study population.

Early Use of Echocardiography in Patients With Acute Pulmonary Embolism: Findings From the RIETE Registry

Background Transthoracic echocardiography ( TTE ) is often considered for risk stratification of patients with acute pulmonary embolism ( PE ). We sought to determine the contemporary utilization of early TTE (within 72 hours of PE diagnosis) and explored the association between TTE findings and PE -related mortality. Methods and Results Data from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry, a multicenter registry of consecutive patients with acute PE , were used (2001-July 2017). We used a generalized linear mixed model to determine predictors of early TTE performance. Moreover, the association between 3 TTE variables (right atrial enlargement, right ventricular hypokinesis, and presence of right heart thrombi) and 30-day PE -related mortality was assessed in generalized linear mixed models adjusted for PE severity index, and other comorbidities. Among 35 935 enrollees with acute PE , 15 375 (42.8%) underwent early TTE . There was an increase in early TTE utilization rate over time ( P<0.001 for trend). Younger age, female sex, enrollment in countries other than Spain, history of coronary disease, heart failure, atrial fibrillation, tachycardia, and hypotension were the main predictors of early TTE ( P<0.01 for all). In multivariable analyses, right atrial enlargement (adjusted odds ratio: 3.74; 95% confidence interval, 2.10-6.66), right ventricular hypokinesis (adjusted odds ratio: 3.11, 95% confidence interval: 1.85-5.21) and right heart thrombi (adjusted odds ratio: 4.39, 95% confidence interval, 1.99-9.71) were associated with increased odds for PE -related mortality. Conclusions Early TTE is commonly performed for acute PE and utilization rates have increased over time. Right atrial enlargement, right ventricular hypokinesis, and right heart thrombi are predictive of worse outcomes. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02832245.

Does Right Ventricular Dysfunction Predict Mortality in Hemodynamically Stable Patients With Acute Pulmonary Embolism?

BACKGROUND

Acute pulmonary embolism (APE) is directly responsible for 100,000 deaths annually. Right ventricular dysfunction (RVD) on admission is considered a poor prognostic factor in these patients, though existing evidence of its significance in predicting mortality in hemodynamically stable patients is still unclear. We attempted to clarify this association by doing a retrospective review.

METHODS

We retrospectively reviewed electronic medical records of hemodynamically stable patients older than 18 years of age with APE who were admitted to a tertiary care hospital in rural Upstate New York from July 2014 to July 2016. One hundred thirty-four patients were reviewed in two groups: patients who presented with computed tomography (CT) or echocardiographic evidence of RVD, and those without RVD. To identify differences in mortality between the two groups, the Chi-square/Fisher's exact test and t-tests were used. All variables with P < 0.2 in the initial analysis were included in a stepwise multivariable logistic regression model to predict RVD.

RESULTS

No statistically significant difference was found in 30-day mortality between the groups (7.8% in RVD and 5.3% in no RVD, P = 0.563). The overall prevalence of RVD was found to be 57% (77/134). Troponin elevation (53.2% in RVD group vs. 19.3 in the no RVD group with P < 0.01) and central location of thrombus (53.1% vs. 32.1% with P = 0.016) were more prevalent in RVD group. A marginally significant difference was found in length of hospital stay among those with RVD versus no RVD (7.13 days vs. 5.46 days; P = 0.061). The multivariable analysis shows that the odds of RVD were greater for patients with elevated troponin levels (odds ratio = 7.8).

CONCLUSION

There was no difference in 30-day mortality in hemodynamically stable patients with APE having RVD compared to patients with no RVD. On the basis of this study, we do not suggest the routine use of systemic fibrinolysis in hemodynamically stable patients with radiographic evidence of RVD alone.