Prognostic value of computed tomographic pulmonary angiography and the pulmonary embolism severity index in patients with acute pulmonary embolism

The relationship between pulmonary artery obstruction index and troponin in thorax computed tomography in pulmonary embolism

Aim: To study the relation between troponin and pulmonary artery obstruction index in thoracic computerized tomography in patients diagnosed with acute pulmonary embolism. Material and Method: Data obtained from patients hospitalized in the ward and intensive care units with a pulmonary embolism diagnosis between January 2016 and February 2022 were scanned retrospectively. The full blood count, D-dimer, C-reactive protein, procalcitonin, troponin I, thoracic computerized tomography (CT), angiography, and bilateral lower extremity venous Doppler ultrasonography data were extracted. Patients with left heart failure, renal failure, gastrointestinal hemorrhage, sepsis, respiratory system disease, burns, ischemic stroke, or subarachnoid hemorrhage were excluded. The obstruction indices were calculated according to storage defects in the main, right, left, lobar, and segmental pulmonary artery branches in CT angiography. Results: While 57.0% of the 69 patients included in the study were female, 42.1% were male. The obstruction index in the high troponin-I group was significantly higher than that in the normal troponin-I group (p=0.006). In addition, the obstruction index was significantly higher in patients with bilateral pulmonary embolism than in those with unilateral pulmonary embolism (

CHA2 DS2 -VASc and PESI scores are associated with right ventricular dysfunction on computed tomography pulmonary angiography in patients with acute pulmonary thromboembolism

BACKGROUND

Accurate risk stratification is the most important step in the management of patients with acute pulmonary thromboembolism (PTE). Pulmonary embolism severity index (PESI) is a clinical tool for PTE risk stratification. CHA₂ DS₂ -VASc score, a risk assessment tool in patients with atrial fibrillation, is recently considered for acute PTE. The presence of right ventricular (RV) dysfunction in imaging is more efficient in acute PTE risk evaluation.

HYPOTHESIS

This study aims to evaluate the association between CHA₂ DS₂ -VASc and PESI score and each of them with RV dysfunction on computed tomography pulmonary angiography (CTPA).

METHODS

One hundred eighteen patients with a definite diagnosis of PTE were entered. The CHA₂ DS₂ -VASc and PESI scores were calculated for all of them. RV dysfunction including an increase in RV to left ventricular diameter ratio, interventricular septal bowing, and reflux of contrast medium into the inferior vena cava was examined by CTPA.

RESULTS

PESI and CHA₂ DS₂ -VASc scores were significantly associated with RV dysfunction. In addition, different classes of PESI scores were correlated with RV dysfunction. Moreover, this study showed that the CHA₂ DS₂ -VASc score and PESI score had a positive correlation. The area under the curve value for the CHA₂ DS₂ -VASc score was 0.625 with 61.54% sensitivity and 60.0% specificity for predicting RV dysfunction while for PESI score was 0.635 with 66.7% sensitivity and 60.0% specificity.

CONCLUSION

This study showed that not only CHA₂ DS₂ -VASc and PESI scores are positively correlated, but they are both associated with RV dysfunction diagnosed by CTPA. CHA₂ DS₂ -VASc and PESI scores are able to predict RV dysfunction.

Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis

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.

Prognostic significance of computed tomography-assessed right ventricular enlargement in low-risk patients with pulmonary embolism: Systematic review and meta-analysis

BACKGROUND

For patients with acute low-risk pulmonary embolism (PE), determined by a validated clinical prognostic score, the additive prognostic significance of computed tomography (CT)-assessed right ventricular (RV) enlargement is uncertain.

METHODS

We performed a systematic review and meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of concomitant CT-assessed RV enlargement for 30-day all-cause mortality and PE-related death. We conducted unrestricted searches of PubMed and Embase through December 2019. We used a random-effects model to pool study results; Begg rank correlation method to evaluate for publication bias; and I² testing to assess for heterogeneity.

RESULTS

Of the 7 cohorts with 2197 participants who had low-risk PE and provided results on the primary outcome, 743 (34%; 95% confidence interval [CI], 32-36%) patients had concomitant RV enlargement. Six of 743 (0.8%; 95% CI, 0.3-1.8%) patients with concomitant RV enlargement died 30-days after the diagnosis of PE compared with 3 of 1454 (0.2%, 95% CI, 0-0.6%) without RV enlargement. CT-assessed RV enlargement did not have a significant association with 30-day all-cause mortality (odds ratio [OR], 2.6; 95% CI, 0.7-9.4; I² = 0%; P = 0.15) or PE-related mortality (OR, 2.8; 95% CI, 0.7-12.1; I² = 0%; P = 0.16).

CONCLUSIONS

CT-assessed RV enlargement occurs in a third of PE patients identified as low-risk by clinical scores. Mortality rate in these patients is low, and CT-assessed RV enlargement was not associated with a significantly increased risk of death within 30 days of PE diagnosis.

Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis

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.

Central Versus Peripheral Pulmonary Embolism: Analysis of the Impact on the Physiological Parameters and Long-term Survival

BACKGROUND

Studies aimed at assessing whether the emboli lodged in the central pulmonary arteries carry a worse prognosis than more peripheral emboli have yielded controversial results.

AIMS

To explore the impact on survival and long-term prognosis of central pulmonary embolism.

PATIENTS AND METHODS

Consecutive patients diagnosed with acute symptomatic pulmonary embolism by means of computed tomography (CT) angiography were evaluated at episode index and traced through the computed system of clinical recording and following-up. Central pulmonary embolism was diagnosed when thrombi were seen in the trunk or in the main pulmonary arteries and peripheral pulmonary embolism when segmental or subsegmental arteries were affected.

RESULTS

A total of 530 consecutive patients diagnosed with pulmonary embolism were evaluated; 255 patients had central pulmonary embolism and 275 patients had segmental or subsegmental pulmonary embolism. Patients with central pulmonary embolism were older, had higher plasma levels of N-terminal of the prohormone brain natriuretic peptide (NT-ProBNP), troponin I, D-dimer, alveolar-arterial gradient, and shock index (P < .001 for each one). Patients with central pulmonary embolism had an all-cause mortality of 40% while patients with segmental or subsegmental pulmonary embolism (PE) had an overall mortality of 27% and odds ratio of 1.81 [confidence interval (CI) 95% 1.16-1.9]. Survival was lower in patients with central PE than in patients with segmental or subsegmental pulmonary embolism, even after avoiding confounders (P = .018).

CONCLUSIONS

Apart from a greater impact on hemodynamics, gas exchange, and right ventricular dysfunction, central pulmonary embolism associates a shorter survival and an increased long-term mortality.

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.

The new oral anticoagulants for the treatment of venous thromboembolism: a new paradigm shift in antithrombotic therapy

Background

Several novel oral anticoagulants have been studied for the prevention and treatment of venous thromboembolism (VTE) in different patient populations. Clinicians will increasingly encounter scenarios in which they must choose among these and conventional anticoagulants for the treatment of this potentially fatal condition.

Objective

To review the results of Phase III clinical trials that investigated the novel oral anticoagulants for the treatment of deep vein thrombosis and pulmonary embolism. Potential advantages and disadvantages of these anticoagulant agents with respect to each other and conventional therapy will also be explored through a case-based approach.

Methods

A literature search in PubMed was conducted that identified Phase III clinical trials investigating the novel oral anticoagulant agents for the treatment of VTE.

Results

The new oral anticoagulant agents have been shown to be as safe and effective for the treatment of VTE as conventional therapies.

Conclusions

These novel, oral anticoagulant agents are legitimate options for the treatment of VTE. A careful assessment of a patient׳s comorbidities, medication use, and laboratory results should be undertaken before prescribing the new oral anticoagulant agents for patients with VTE.

Prognostic role of embolic burden assessed at computed tomography angiography in patients with acute pulmonary embolism: systematic review and meta-analysis

BACKGROUND

In patients with acute pulmonary embolism (PE), risk stratification is indicated for tailoring of both diagnostic strategies and acute treatment. Whether embolic burden assessed at computed tomography (CT) angiography has a role in risk stratification in these patients is debated.

OBJECTIVE

To systematically review and perform a meta-analysis to evaluate the role of CT-assessed burden associated with embolic obstruction and embolic localization in the prognostic stratification of patients with acute PE.

METHODS

We performed a systematic search in EMBASE and MEDLINE up until 30 June 2013. Studies reporting on the 30-day outcome of patients with confirmed PE and CT-assessed embolic burden were included. The study outcome was death.

RESULTS

Thirty studies reporting on the prognostic value of CT-assessed embolic burden met the inclusion criteria for this systematic review; of these, 19 were included in the meta-analysis. Five studies (2215 patients) were included in the analysis of localization: an association between embolus localization in the central arteries and 30-day mortality was found after heterogeneity was resolved (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.29-3.89, I(2)  = 0%). No correlation was observed between obstruction index (according to the Qanadli scoring system) and 30-day mortality after heterogeneity was reduced (16 studies, 3884 patients, OR 1.22, 95% CI 0.99-1.51, I(2)  = 27%).

CONCLUSION

Localization of emboli assessed at CT angiography can be used for risk stratification in patients with acute PE. Moreover, no correlation was observed between obstruction index and prognosis.