Prognosis assessment of acute pulmonary embolism by multimodality imaging: Is it really necessary?

Abstract

Prognostic assessment of pulmonary embolism (PE) by transthoracic echocardiography (TTE) and CT-scan has been proposed in patients with intermediate risk according to the ESC guidelines. The aim of this study is to assess the accuracy of this multimodality imaging strategy in routine practice. We reviewed from our database all consecutive patients hospitalized for acute PE between July 2011 and June 2019. Right ventricular (RV) size/dysfunction was systematically assessed by TTE and CT-scan in patients classified as intermediate risk (defined as a sPESI score ≥ 1) and was defined as RV/LV ratio ≥ 1. In-hospital outcome was systematically assessed and was compared according to the classification of PE severity and the combined use of TTE and CT-scan and the separated use of these 2 imaging modalities. We studied 708 patients (49.5% female, median age 68 years) presenting with acute PE. 50 patients (7%) had shock or hypotension on arrival, meeting the criteria for high-risk PE with an in-hospital mortality of 38%. Among the 658 patients without high-risk PE, 336 patients had a sPESI score ≥ 1 and were considered as intermediate risk PE. TTE classified 124 patients as intermediate–high risk PE versus 132 patients by CT-scan, 165 patients by TTE or CT-scan and 91 patients by both TTE and CT-scan. In intermediate-high risk PE (RV dysfunction), in-hospital mortality was 11.3% using TTE alone, 9.8% using CT-scan alone, 9.1% with positive TTE or CT-scan and 13.2% using TTE and CT-scan ( P = 0.75). In-hospital mortality was 5.6% in intermediate-low risk PE and 0.6% in low risk PE (sPESI = 0). In intermediate-high risk PE, the accuracy of combined TTE and CT-scan or TTE or CT-scan used alone is similar for the assessment of PE prognosis.