Troponin-based risk stratification of patients with acute nonmassive pulmonary embolism: systematic review and metaanalysis.
BACKGROUND
Controversy exists regarding the usefulness of troponin testing for the risk stratification of patients with acute pulmonary embolism (PE). We conducted an updated systematic review and a metaanalysis of troponin-based risk stratification of normotensive patients with acute symptomatic PE. The sources of our data were publications listed in Medline and Embase from 1980 through April 2008 and a review of cited references in those publications.


METHODS
We included all studies that estimated the relation between troponin levels and the incidence of all-cause mortality in normotensive patients with acute symptomatic PE. Two reviewers independently abstracted data and assessed study quality. From the literature search, 596 publications were screened. Nine studies that consisted of 1,366 normotensive patients with acute symptomatic PE were deemed eligible. Pooled results showed that elevated troponin levels were associated with a 4.26-fold increased odds of overall mortality (95% CI, 2.13 to 8.50; heterogeneity chi(2) = 12.64; degrees of freedom = 8; p = 0.125). Summary receiver operating characteristic curve analysis showed a relationship between the sensitivity and specificity of troponin levels to predict overall mortality (Spearman rank correlation coefficient = 0.68; p = 0.046). Pooled likelihood ratios (LRs) were not extreme (negative LR, 0.59 [95% CI, 0.39 to 0.88]; positive LR, 2.26 [95% CI, 1.66 to 3.07]). The Begg rank correlation method did not detect evidence of publication bias.


CONCLUSIONS
The results of this metaanalysis indicate that elevated troponin levels do not adequately discern normotensive patients with acute symptomatic PE who are at high risk for death from those who are at low risk for death.
Jiménez
David
D
Respiratory Department, Ramón y Cajal Hospital, Madrid, Spain. Electronic address: djc_69_98@yahoo.com.
Uresandi
Fernando
F
Respiratory Department, Cruces Hospital, Bilbao, Spain.
Otero
Remedios
R
Respiratory Department, Virgen del Rocío Hospital, Sevilla, Spain.
Lobo
José Luis
JL
Respiratory Department, Txagorritxu Hospital, Vitoria, Spain.
Monreal
Manuel
M
Medicine Department, Germans Trias i Pujol Hospital, Barcelona, Spain.
Martí
David
D
Cardiology Department, Ramón y Cajal Hospital, Madrid, Spain.
Zamora
Javier
J
Biostatistics Unit, Ramón y Cajal Hospital, Madrid, Spain.
Muriel
Alfonso
A
Biostatistics Unit, Ramón y Cajal Hospital, Madrid, Spain.
Aujesky
Drahomir
D
Division of General Internal Medicine, University of Lausanne, Lausanne, Switzerland.
Yusen
Roger D
RD
Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO.
D006801:Humans; D011655:Pulmonary Embolism / Q000401:mortality*; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D014336:Troponin / Q000097:blood*
D014336:Troponin