Prognosis Of Acute Pulmonary Embolism Research Articles

Lack of functional information explains the poor performance of ‘clot load scores’ at predicting outcome in acute pulmonary embolism

Clot load scores have previously been developed with the goal of improving prognosis in acute pulmonary embolism (PE). These scores provide a simple estimate of pulmonary vascular bed obstruction, however they have not been adopted clinically as they have poor correlation with mortality and right ventricular (RV) dysfunction. This study performed a quantitative analysis of blood flow and gas exchange in 12 patient-specific models of PE, to understand the limitations of current clot load scores and how their prognostic value could be improved. Prediction of hypoxemia in the models when using estimated baseline (non-occluded) minute ventilation and cardiac output correlated closely with clinical metrics for RV dysfunction, whereas the clot load score had only a weak correlation. The model predicts that large central clots have a greater impact on function than smaller distributed clots with the same total clot load, and that the partial occlusion of a vessel only has a significant impact on pulmonary function when the vessel is close to completely occluded. The effect of clot distribution on the redistribution of blood from its normal pattern – and hence the magnitude of the potential effect on gas exchange – is represented in the model but is not included in current clot load scores. Improved scoring systems need to account for the expected normal distribution of blood in the lung, and the impact of clot on redistributing the blood flow.

Platelet size deviation width measured at hospital admission predicts in-hospital mortality and all cause mortality at follow up after discharge in acute pulmonary embolism

Introduction: Platelet distribution width (PDW) directly measures the variability in platelet size and it has been postulated that large platelets may be an indi- cator of platelet activation. No data has been reported so far about the impact of this index on prognosis of acute pulmonary embolism (APE). Thus, the aim of this study was to assess the impact of PDW measured at hospital admission on both in-hospital and after discharge prognosis in patients with APE diagnosed by multislice computed tomography (MSCT). Methods and population: Retrospective, observational study that included all patients with APE diagnosed by MSCT during emergency room (ER) stay in the year of 2010. Blood tests, including PDW, were obtained at hospital admission. The primary endpoint was in-hospital death of all causes. The secondary endpoint was all-cause death at follow-up. A receiver operating characteristics (ROC) curve was used to test PDW as a predictor of the primary endpoint and to obtain the best cut-off point. Then we transformed PDW into a categorical variable with 2 groups and conducted a univariate regression analysis to test the strength of prediction. We then performed analysis for the secondary endpoint, testing the cutoff in a Cox regression model. Results: Between January and December 2010, 218 patients were diagnosed APE by MSCT (age 73±16 years, 102 males). For the outcome in-hospital mortality, area under the curve (AUC) was 0,741 (p≤ 0,001). We considered the best cut off point to be 17,55 (sensitivity 68%, specificity 78%). In the univariate regression analysis, a PDW higher than 17,55 was found to be strongly associated to worse outcome [odds ratio (OR) 7,212; 95% confidence interval (CI) 2,852–18,233; p≤0,001)]. For the outcome all cause mortality at follow up after discharge, AUC was 0,623 (p=0,01). A 17,45 cut off point was found to predict the secondary endpoint with a sensitivity of 48% and a specificity of 73%. In a Cox regression analysis, a value higher than the cut-off was associated with lower event-free survival (hazard ratio (HR) 2,52; 95% CI 1,46-4,35; p≤0,001). Conclusion: PDW is a predictor of both in-hospital mortality and all cause mortality at follow-up after APE.

New ECG index as a marker of poor prognosis in acute pulmonary embolism: ST-segment elevation in lead aVR plus ST-segment depression in lateral leads

Background: ST-segment elevation in lead aVR (STE-aVR) plus ST-segment depression in the lateral leads (STD-lat) is associated with a poor prognosis in acute coronary syndromes. The aim of the study was to determine the value of STE-aVR plus STD-lat in patients with acute pulmonary embolism (APE). Methods: We analyzed ECG and clinical data of 470 patients (pts) with APE, mean age 65.9±15.2 years old, female 274 pts. The new ECG index STE-aVR plus STD-lat was detected in 96 (20.8%) pts. ECG on admission was compared for STE-aVR plus STD-lat (+) (n= 96 pts) or (-) (n= 374 pts). Chi square and T student were used to compare dichotomic and continuous variables. A p value =/- than 0.05 was considered significant. Results: Comparison of both groups can be seen in the table. There were 50 (10.6%) cardiac deaths in the whole population. View this table: Conclusions: The new ECG index STE-aVR plus STD-lat predicts poor prognosis in patients with APE. Patients with this ECG index present two-fold higher risk of complications, 2-fold higher risk of cardiac death, 3-fold more frequent use of inotropoic drugs and 4-fold higher need of ventilation support.

GW24-e3549 Role of heart-type fatty acid-binding protein in assessing prognosis of acute pulmonary embolism

ObjectivesTo study the role of heart-type fatty acid-binding protein (H-FABP) in assessing prognosis of acute pulmonary embolism (APE).MethodsThe levels of plasmid H-FABP and cTnI and D-Dimer in 72 patients with...

New ECG index as a marker of poor prognosis in acute pulmonary embolism: ST segment elevation in lead aVR with ST segment depression in lateral leads

New ECG index as a marker of poor prognosis in acute pulmonary embolism: ST segment elevation in lead aVR with ST segment depression in lateral leads

Prediction of right ventricular dysfunction from radiographic estimates of right descending pulmonary artery in hemodynamically stable pulmonary embolism patients

The evaluation of right ventricular (RV) dysfunction by echocardiography is one of the most important established determinants of the prognosis of acute pulmonary embolism. The aim of the study was to investigate possible association between diameter of right descending pulmonary artery on chest X-rays and RV dysfunction by echocardiography in hemodynamically stable pulmonary embolism patients. Eighty-nine patients with the diagnosis of hemodynamically stable pulmonary embolism were included. The frequency of RV dysfunction was significantly higher in patients with an enlarged right descending pulmonary artery on chest X-rays (p = 0.001). There was a significant positive correlation between the diameter of the right descending pulmonary artery on postero-anterior chest X-rays and the diameter of the RV (r = 0.469; p = 0.002). Diameter of right descending pulmonary artery on chest X-rays was also found as a significant predictor of RV dysfunction besides the troponin-T levels and systolic pulmonary arterial pressure (p < 0.05). Diameter of right descending pulmonary artery on chest X-rays may provide information about the risk for pulmonary embolism patients and may be used as a prognostic radiological parameter for the appropriate management of acute pulmonary embolism.

The prognostic value of pro-B-Type natriuretic peptide in acute pulmonary embolism

AimsTo assess the clinical performance of pro-B-type natriuretic peptide 1-108 (proBNP) for the prognosis of acute pulmonary embolism. MethodsThis study was ancillary to a recently published multicentre study including 570 patients with acute pulmonary embolism. ProBNP values were analysed using a new sandwich immunoassay proBNP1-108, Bioplex2200™ (Bio-Rade Laboratories). Data was compared with BNP and N-terminal (NT) proBNP values. Adverse outcomes at 30days were defined as death, secondary cardiogenic shock, or recurrent venous thromboembolism. RésultsProBNP values were analysed in 549 patients, with 39 (7.1%) presenting adverse outcomes. All three natriuretic peptides were significantly elevated in these 39 patients compared with the group without adverse outcomes (BNP: p <0.001; NT-proBNP: p <0.001; proBNP: 0.044), with median proBNP values being 605pg/ml (113-1437) and 109pg/ml (30-444), respectively. Multivariate analyses revealed that proBNP significantly depended on patient age (p <0.001) and renal failure (p=0.001), with proBNP values increasing with both factors. The areas under the receiver operating curve were 0.74 (95% CI 0.69-0.79) for BNP, 0.76 (95% CI 0.72-0.80) for NT-proBNP, and 0.70 (95% CI 0.65-0.75) for proBNP, meaning that the performance of proBNP was significantly lower than that of the two other peptides (p=0.017). ConclusionProBNP, BNP, and NT-proBNP values were significantly increased in patients with adverse outcomes after acute pulmonary embolism. However, the prognostic performance of proBNP for predicting adverse versus favourable outcomes was lower than that of the other natriuretic peptides, thus limiting the clinical relevance of proBNP as a prognostic marker in pulmonary embolism.

Neutrophil gelatinase-associated lipocalin, cystatin C and eGFR indicate acute kidney injury and predict prognosis of patients with acute pulmonary embolism

ObjectiveRisk stratification in acute pulmonary embolism (APE) includes the assessment of clinical status, right ventricular dysfunction and troponin concentrations. Since acute renal impairment is one of the important predictors of...

C-Reactive Protein in Acute Pulmonary Embolism

BackgroundRight ventricular dysfunction and N-terminal proB-type natriuretic peptide (NT-proBNP) are established determinants of prognosis in acute pulmonary embolism (PE). The aim of the study was to investigate the prognostic value...

Diagnosis and prognosis of acute pulmonary embolism: focus on serum troponins

Pulmonary embolism is a common disease associated with high mortality. Death due to pulmonary embolism occurs mainly before hospital admission or in the first hours of the hospital stay. Prompt diagnosis and prognostic stratification and more intensive treatment in patients with estimated high risk for adverse outcomes have the potential to reduce mortality due to pulmonary embolism. Significant advances have recently been made in the risk stratification for adverse outcomes in patients with pulmonary embolism and normal blood pressure. In these patients, right ventricle overload assessed by echocardiography and probably by helical computerized tomography is a predictor of in-hospital mortality. Serum troponin is rapidly available in the emergency room, and has a critical role in the management of patients with acute coronary syndromes. The role of serum troponin in patients with pulmonary embolism has been explored recently: it seems to be marginal in diagnosis while it can significantly contribute to prognostic stratification. Elevated serum levels of troponins are associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism and normal blood pressure.

Prognostic Value of Echocardiographic Right/Left Ventricular End-Diastolic Diameter Ratio in Patients With Acute Pulmonary Embolism: Results From a Monocenter Registry of 1,416 Patients

In the literature, echocardiographic assessment of the prognosis of acute pulmonary embolism is based on analysis of right ventricle free-wall motion or on a composite index combining right ventricular dilatation, paradoxical septal wall motion, and pulmonary hypertension. The aim of this study was to determine the prognostic value of a single quantitative echocardiographic criterion, the right/left ventricular end-diastolic diameter (RV/LV) ratio. Registry data on 1,416 consecutive patients hospitalized for acute pulmonary embolism were used to study retrospectively a population of 950 patients who underwent echocardiographic assessment on hospital admission and for whom the RV/LV ratio was available. The hospital mortality rate for the series was 3.3%. Sensitivity and specificity of RV/LV ratio >or= 0.9 for predicting hospital mortality were 72% and 58%, respectively. Multivariate analysis showed the independent predictive factors for hospital mortality to be the following: systolic BP < 90 mm Hg (odds ratio [OR], 10.73; p < 0.0001), history of left heart failure (OR, 8.99; p < 0.0001), and RV/LV ratio >or= 0.9 (OR, 2.66; p = 0.01). In our retrospective series, an echocardiographic RV/LV ratio >or= 0.9 was shown to be an independent predictive factor for hospital mortality. This criterion may be of value in selecting cases of submassive pulmonary embolism with a poor prognosis that are liable to benefit from thrombolytic treatment.

Computed Tomography Pulmonary Angiography and Venography: Diagnostic and Prognostic Properties

Computed tomography pulmonary angiography (CTPA) is now an established test in the diagnosis of suspected pulmonary embolism (PE). Some may argue that it has become the "one-stop" center for diagnosis and prognosis of acute PE and deep vein thrombosis (DVT). Current literature shows CTPA to be reliable and accurate. Management studies have shown patient outcomes are excellent when CTPA is used in the diagnostic algorithm. The addition of computed tomography venography (CTV) increases the sensitivity, which may be worth the added radiation in certain patient populations. Although measures of right heart function, pulmonary artery pressures, and clot burden via CTPA need to be standardized and further validated prospectively, this test may also play a prominent role in determining short-term outcomes in patients with established acute PE.

Prognostic Value of Arterial/Alveolar Oxygen Tension Ratio (a/APO2) in Acute Pulmonary Embolism

Because the arterial/alveolar oxygen tension ratio (a/APO2) is relatively constant throughout the entire range of fractional inspired oxygen concentration (FiO2), its use in determining the prognosis of acute pulmonary embolism (APE) was investigated. This study retrospectively assessed 202 consecutive patients with APE confirmed by computed tomography or high probability lung scintigraphy. All patients underwent initial arterial blood gas analysis during the first 24 h of admission. Receiver-operating characteristic analyses were performed to determine the a/APO2 cut-off value for predicting 30-day death or 30-day composite events. Cut-off values for a/APO2 were used to determine stability in all patients and 2 subgroups (0.49 for all patients; 0.49 for FiO2 =0.21; 0.46 for FiO2 >0.21). Using the cut-off value of a/APO2 <0.49 for predicting 30-day death, the negative predictive value (NPV) was 90%, and the positive predictive value (PPV) was 30.3%. For the 30-day composite end point, the NPV was 81.3%, and the PPV was 40.9%. Excluding massive APE, the a/APO2 also had high NPV and moderate PPV in predicting short-term prognosis. This study additionally demonstrated a linear relationship between platelet count and a/APO2. The cut-off value of a/APO2 <0.49 exhibits stability at variable FiO2 values and is a useful prognostic predictor in APE.

Prognostic Role of Alveolar-Arterial Oxygen Pressure Difference in Acute Pulmonary Embolism

This study investigated the utility of the alveolar - arterial oxygen pressure difference (AaDO (2)) in predicting the short-term prognosis of acute pulmonary embolism (PE). This study retrospectively enrolled 114 consecutive patients with acute PE, diagnosed by either spiral computed tomography or high probability ventilation - perfusion lung scans. During the first 24 h of admission, all patients had initial artery blood gas collected under room air. Patient exclusion criteria were chronic lung disease, septic emboli, and moderate and low probability lung scans. Patients were assigned to 2 groups based on either 30-day death or a 30-day composite event. Receiver operating characteristic analyses was used to determine the AaDO(2) cut-off value for predicting primary and composite endpoints. Statistical analysis demonstrated significant differences in AaDO(2) between the 30-day composite endpoint group and the 30-day composite event-free survival group (p=0.012). The AaDO(2) had a strong trend between the 30-day death group and the survival group (p=0.062). The best cut-off value for AaDO(2) was 53 mmHg and using this, the positive predictive value for 30-day death was 25% and the negative predictive value was 92%. For the 30-day composite endpoint, the positive predictive value for AaDO(2) was 35%, and the negative predictive value was 84%. In this study, thrombocytopenia was also an indicator of poor prognosis for patients with acute PE. The AaDO(2) measurement is a highly useful and simple measurement for predicting short-term prognosis in patients with acute PE. It has high negative predictive value and moderate positive predictive value for 30-day death and 30-day composite event. Aggressive thrombolytic treatment strategies should be considered for patients with an initial poor prognostic parameter (ie, AaDO(2) >or=53 mmHg).

Clinical course and prognosis of acute pulmonary embolism

Effective treatment of acute pulmonary embolism (PE) requires prompt identification of patients at high risk of death or severe cardiovascular complications during the hospital stay. Determination of prognostic parameters in this heterogeneous patient population is far more important than calculation of a crude mortality rate due to PE. The multicenter Management Strategy and Prognosis in Pulmonary Embolism Registry examined the in-hospital clinical course of 1001 consecutive patients with acute PE. Overall mortality was 22%, with 91% of deaths directly related to PE. Clinical signs of acute right heart failure due to major PE (arterial hypotension, shock, circulatory collapse) were clearly associated with an adverse outcome. Mortality ranged from 8 to 65% depending on the severity of clinical instability at presentation. Importantly, a significantly increased death rate was also observed in patients with echocardiographically detected right ventricular dilation (84 vs. 16%), a reliable noninvasive index of impending right heart failure. The independent prognostic effect of this finding was confirmed by multivariate analysis (Odds Ratio, 2.44; P=0.004). Thus, the combination of clinical and echocardiographic findings permits accurate risk stratification of patients with acute PE. Evidence is also accumulating that these prognostic factors can be used to identify candidates for early thombolytic treatment.

Late prognosis of acute pulmonary embolism.

Sixty consecutive patients who survived an episode of acute pulmonary embolism documented by pulmonary angiography were assessed one to seven years later (average follow-up period, 29 months) to determine long-term prognosis. Thirty-nine were alive, 19 (32 per cent) had died, and two were lost to follow-up study. Survival largely depended on cardiac status before embolism. Of 42 patients without left ventricular failure, 36 survived. However, of 16 with failure before embolism, only three survived. Follow-up lung scans and arterial-blood gases in the survivors and autopsy in those who died demonstrated resolution of embolism in most patients. Of 43 with adequate follow-up data, resolution was complete in 28 (65 per cent) and partial in 10 (23 per cent); unresolved embolism persisted in only five patients (12 per cent), with resultant chronic cor pulmonale in only one. Recurrent embolism was documented in only one. The long-term prognosis of patients who survive acute embolism thus appears to be dependent on the presence or absence of prior heart disease. (N Engl J Med 289:55–58, 1973)