Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism.
BACKGROUND
In haemodynamically stable patients with acute symptomatic pulmonary embolism (PE), studies have not evaluated the usefulness of combining the measurement of cardiac troponin, transthoracic echocardiogram (TTE), and lower extremity complete compression ultrasound (CCUS) testing for predicting the risk of PE-related death.


METHODS
The study assessed the ability of three diagnostic tests (cardiac troponin I (cTnI), echocardiogram, and CCUS) to prognosticate the primary outcome of PE-related mortality during 30 days of follow-up after a diagnosis of PE by objective testing.


RESULTS
Of 591 normotensive patients diagnosed with PE, the primary outcome occurred in 37 patients (6.3%; 95% CI 4.3% to 8.2%). Patients with right ventricular dysfunction (RVD) by TTE and concomitant deep vein thrombosis (DVT) by CCUS had a PE-related mortality of 19.6%, compared with 17.1% of patients with elevated cTnI and concomitant DVT and 15.2% of patients with elevated cTnI and RVD. The use of any two-test strategy had a higher specificity and positive predictive value compared with the use of any test by itself. A combined three-test strategy did not further improve prognostication. For a subgroup analysis of high-risk patients, according to the pulmonary embolism severity index (classes IV and V), positive predictive values of the two-test strategies for PE-related mortality were 25.0%, 24.4% and 20.7%, respectively.


CONCLUSIONS
In haemodynamically stable patients with acute symptomatic PE, a combination of echocardiography (or troponin testing) and CCUS improved prognostication compared with the use of any test by itself for the identification of those at high risk of PE-related death.
Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Madrid, Spain. djc_69_98@yahoo.com
David
D
Jiménez
Drahomir
D
Aujesky
Lisa
L
Moores
Vicente
V
Gómez
David
D
Martí
Sem
S
Briongos
Manuel
M
Monreal
Vivencio
V
Barrios
Stavros
S
Konstantinides
Roger D
RD
Yusen
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D001794:Blood Pressure / Q000502:physiology; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011655:Pulmonary Embolism / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000188:drug therapy; D016896:Treatment Outcome; D019210:Troponin I / Q000097:blood; D014463:Ultrasonography; D020246:Venous Thrombosis / Q000150:complications / Q000000981:diagnostic imaging; D018497:Ventricular Dysfunction, Right / Q000150:complications / Q000000981:diagnostic imaging
D015415:Biomarkers; D019210:Troponin I