Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism (original) (raw)
Multidisciplinary Respiratory Medicine, 2013
Background: To investigate whether 2 cardiac troponins [conventional troponin-T(cTnT) and high sensitive troponin-T(hsTnT)] combined with simplified pulmonary embolism severity index (sPESI), or either test alone are useful for predicting 30-day mortality and 6 months adverse outcomes in patients with normotensive pulmonary embolism(PE). Methods: The prospective study included 121 consecutive patients with normotensive PE confirmed by computerized tomographic(CT) pulmonary angiography. The primary end point of the study was the 30-day all-cause mortality. The secondary end point included the 180-day all-cause mortality, the nonfatal symptomatic recurrent PE, or the nonfatal major bleeding. Results: Overall, 16 (13.2%) out of 121 patients died during the first month of follow up. The predefined hsTnT cutoff value of 0.014 ng/mL combined with a sPESI ≥1 'point(s) were the most significant predictor for 30-day mortality [OR: 27.6 (95% CI: 3.5-217) in the univariate analysis. Alone, sPESI ≥1 point(s) had the highest negative predictive value for both 30-day all-cause mortality and 6-months adverse outcomes,100% and 91% respectively. The hsTnT assay combined with the sPESI may provide better predictive information than the cTnT assay for early death of PE patients. Low sPESI (0 points) may be used for identifying the outpatient treatment for PE patients and biomarker levels seem to be unnecessary for risk stratification in these patients.
Chest, 2003
Study objectives: Indications for thrombolysis in normotensive patients with pulmonary embolism (PE), based on the presence of right ventricular (RV) overload during transthoracic echocardiography (TTE), are controversial. We checked whether the monitoring of cardiac troponin T (cTnT) might help in risk stratification by detecting patients with RV myocardial injury. Patients and design: We studied 64 normotensive patients (30 women and 34 men) with a mean (؎ SD) age of 61.3 ؎ 17 years and PE, who had undergone TTE for the assessment of RV overload. Plasma cTnT levels were measured quantitatively (detection limit, > 0.01 ng/mL) at hospital admission, and subsequently three times at 6-h intervals. Heparin therapy alone was used in 87.5% of patients, while 12.5% of patients received thrombolysis. Results: cTnT was detected in 50% of patients. All eight in-hospital deaths occurred in the troponin-positive group, however, in one case the results of the first three assays had been negative. Elevated plasma cTnT increased the risk of PE-related death (odds ratio [OR], 21; 95% confidence interval [CI], 1.2 to 389). Increased age and elevated tricuspid regurgitant jet velocity, but not RV diameter/left ventricle diameter ratio, influenced the hospital mortality rate. Increased cTnT level was the only parameter predicting 15 in-hospital clinical adverse events (ie, death, thrombolysis, cardiopulmonary resuscitation, and IV use of catecholamine agents) [OR, 24.1; 95% CI, 2.9 to 200]. Conclusions: Patients with PE and elevated cTnT levels detected during repetitive assays are at a significant risk of a complicated clinical course and fatal outcome.
Early Risk Stratification Of Patients With Acute Pulmonary Embolism: Role Of Cardiac Troponin I
abstract Background: The early assessment of risk and appropriate management of patients with acute pulmonary embolism (APE) remains a challenge. Objective: This study is planned to evaluate the prognostic significance of cardiac troponin I (cTnI) levels in predicting in-hospital haemodynamic instability, complicated clinical course and mortality in patients with APE. Patients and methods: This study included 42 patients with APE who were haemodynamically stable at the time of admission. According to the level of cTnI, the patients were divided into two groups. The first group involved patients with APE and elevated cTnI levels (cTnI positive group), it included 18 patients (42%) with a mean cTnI value of 0.39±0.23 ng/ml, a range of 0.08 – 0.9 ng/ml and a median of 0.36 ng/ml. the second group involved patients with APE and normal cTnI levels (cTnI negative group) , it included 24 patients with normal cTnI levels (<0.01 ng/ml). All patients were subjected to history taking and complete clinical examination including measurement of blood pressure, assessment of partial pressures of O 2 (PaO 2) and carbon dioxide (PaCO2), D-dimer, total creatine kinase (CK) and CK-MB isoenzyme and cardiac troponin I,. All patients were subjected to electrocardiography (ECG) and echocardiography.Pulmonary embolism was diagnosed by helical computed tomography(CT) angiography.
Thrombosis research, 2010
Background: Right ventricular dysfunction (RVD) detected by computerized tomography (CT)/echocardiography or elevated biomarkers is associated with a poor prognosis for pulmonary embolism (PE). However, these prognostic factors have not previously been concomitantly elucidated in the same patient group. Methods: This prospective study included 108 consecutive patients with normotensive PE confirmed by CT pulmonary angiography (CTPA). On admission, patient serum NT-proBNP and troponin T (Tn-T) levels were measured, and echocardiography was performed within 24 hours after diagnosis of PE. Receiver operating characteristic (ROC) analysis was performed to determine the optimal echocardiographic end-diastolic diameters of the right ventricle, the ratio of the right ventricle to left ventricle (RV/LV ratio) on CTPA, and NT-proBNP and Tn-T cut-off levels with regard to prognosis. Results: All-cause 30-day mortality was 13% and PE-related mortality was 5.6%. RVD was defined as a right/left ventricular dimension ratio ≥ 1.1 on CTPA and RV N30 mm on echocardiography by ROC analysis. A cut-off level of NT-proBNP ≤ 90 pmol/ml had a high positive predictive value of 98% for survival, whereas NT-proBNP N 300 and Tn-T ≥ 0.027 had a negative predictive value, for all-cause deaths, of 95% and 96%, respectively. PE mortality in patients with NT-proBNP N 300 and Tn-T ≥ 0.027 reached 64%. In univariable analysis, the combination of Tn-T ≥ 0.027 ng/ml with a echocardiographic RVD were the most significant predictors of overall mortality and PE-related death ) and HR: 37.6 (95% CI: 4.4-324)], respectively. In multivariable Cox's regression analysis, NT-proBNP N300 and Tn-T ≥ 0.027 HR: 26.5 (95% CI: 4.1-169.9, p b 0.001) were the best combination to predict all-cause of mortality. Conclusions: The combination of NT-proBNP and Tn-T clearly appears to be a better risk stratification predictor than biomarkers plus RVD on CT/ echocardiography in patients with normotensive PE.
European Respiratory Journal, 2012
We analysed a cohort of patients with normotensive pulmonary embolism (PE) in order to assess whether combining echocardiography and biomarkers with the pulmonary embolism severity index (PESI) improves the risk stratification in comparison to the PESI alone. The PESI was calculated in normotensive patients with PE who also underwent echocardiography and assays of cardiac troponin I and brain natriuretic peptide. 30-day adverse outcome was defined as death, recurrent PE or shock. 529 patients were included, 25 (4.7%, 95% CI 3.2-6.9%) had at least one outcome event. The proportion of patients with adverse events increased from 2.1% in PESI class I-II to 8.4% in PESI class III-IV, and to 14.3% in PESI class V (p,0.001). In PESI class I-II, the rate of outcome events was significantly higher in patients with abnormal values of biomarkers or right ventricular dilatation. In multivariate analysis, the PESI (class III-IV versus I-II, OR 3.1, 95% CI 1.2-8.3; class V versus I-II, OR 5.5, 95% CI 1.5-25.5 and echocardiography (right ventricular/left ventricular ratio, OR (for an increase of 0.1) 1.3, 95% CI 1.1-1.5) were independent predictors of an adverse outcome. In patients with normotensive PE, biomarkers and echocardiography provided additional prognostic information to the PESI.
The Value of Cardiac Troponins in Diagnosis and Differential Diagnosis of Pulmonary Embolism
Journal of Pulmonary & Respiratory Medicine, 2013
Aim: Pulmonary Embolism (PE) is a major cause of deaths in hospitals. Early diagnosis and emergent treatment decrease mortality rate. Cardiac troponins are thought to be useful in early diagnosis and especially in predicting PE prognosis. The aims of this study are 1) to investigate the diagnostic importance of cardiac troponins in PE and 2) to evaluate the relationship between disease severity, right ventricular dilatation and high levels of cardiac troponins. This study also aims to determine the role of cardiac troponins in differential diagnosis of PE from other pulmonary diseases that may also cause hypoxemia. Methods: A total number of 117 patients, 59 of whom, diagnosed with PE (group I) and 58 with asthma attack and community acquired pneumonia (group II) were enrolled in the study. Cardiac troponin T (cTnT) and I (cTnI) levels were measured twice in all patients during inclusion and within 12 hours. Clinical and laboratory findings were recorded. Results: cTnT and cTnI were positive in 8 (13.6%) and 48 (81.3%) patients in group I and in 1 (1.7%) and 47 (81.3%) patients in group II (1.72%), respectively (p=0.03 and 1.7). Mean cTnI levels were 3.92 ± 2.65 ng/ml in group I and 3.30 ± 2.93 ng/ml in group II (p>0.05). In existence of hpoxemia (PaO 2 ≤ 55mmHg), there was no correlation between groups and cTnT and cTnI levels. Cardiac troponin levels were more positive in patients who had echocardiographic pathology due to pulmonary embolism. cTnT and cTnI elevation was not found to be related with the clinical severity of PE, however massive PE cases had high troponin levels. The sensitivity, specificity, PPV and NPV of cTnI (cut-off value 2.935 ng/ml) and cTnT positivity (>0.01 ng/ml) were found as 66.1%, 60.3%, 62.9%, 63.6%, and 13.6%, 98.3%, 88.9%, and 52.8%, respectively. Troponin I was a differential factor for patients with pulmonary embolism when it was compared with controls, although it was no very sensitive. Mortality rate was 7.4% and high levels of cTnI positivity (≥3 ng/ml) were detected in these cases in present study. Conclusion: Cardiac troponins might be a role in differential diagnosis for PE, but we should be kept in mind that they could be elevated in pneumonia and asthma attack. Another result of this study suggests that cardiac troponins might be useful parameter for detection of right ventricular dysfunction, prediction of mortality and massive disease in PE patients.