title: Relation Among Clot Burden, Right-Sided Heart Strain, and Adverse Events After Acute Pulmonary Embolism.
abstract: Computed tomography pulmonary angiogram (CTPA) provides a volumetric assessment of clot burden in acute pulmonary embolism (PE). However, it is unclear if clot burden is associated with right-sided heart strain (RHS) or adverse clinical events (ACE). We prospectively enrolled Emergency Department patients with PE (in CTPA) from 2008 to 2011. We assigned 1 to 9 points as clot burden score, based on whether emboli were saddle, central, lobar, segmental, and subsegmental. We evaluated a novel score (the "CT-PASS") based on the sum (in millimeters) of the largest filling defects in the right and left pulmonary vasculature. Our primary outcome was RHS, defined by imaging (echocardiography or CTPA) or cardiac biomarkers. Our secondary outcomes included 5-day ACE. We included 271 patients (50% women), with a mean age of 59 ± 17 years. Based on CTPA, 131 patients (48%) had central PE (clot burden score ≥5 points). The median CT-PASS was 9.1 mm (interquartile range 4.9 to 16.4). In univariate analysis, higher clot burden (highest quartile CT-PASS) was associated with RHS (p = 0.003). In multivariate analysis, after adjusting for RHS, age, and gender, central PE (odds ratio [OR] 2.92, 95% confidence interval [CI] 1.10 to 7.81) and CT-PASS >20 mm (OR 3.54, 95% CI 1.39 to 8.97) were significantly associated with ACE. However, this association of central PE with ACE was not statistically significant after excluding patients with shock index >1 (OR 2.56, 95% CI 0.62 to 10.64). In conclusion, highest quartile CT-PASS was associated with RHS and central PE and ACE, but this association was not statistically significant in hemodynamically stable PE [corrected].
authors.affiliation: Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Praveen
authors.initials: P
authors.lastname: Hariharan
authors.affiliation: Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: David M
authors.initials: DM
authors.lastname: Dudzinski
authors.affiliation: Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Rachel
authors.initials: R
authors.lastname: Rosovsky
authors.affiliation: Department of Radiology, Inova Fairfax Hospital, Falls River, Virginia.
authors.forename: Farris
authors.initials: F
authors.lastname: Haddad
authors.affiliation: Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland.
authors.forename: Peter
authors.initials: P
authors.lastname: MacMahon
authors.affiliation: Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Blair
authors.initials: B
authors.lastname: Parry
authors.affiliation: Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.affiliation: Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: ckabrhel@partners.org.
authors.forename: Christopher
authors.initials: C
authors.lastname: Kabrhel
mesh_terms: D000208:Acute Disease; D001777:Blood Coagulation / Q000502:physiology*; D000072226:Computed Tomography Angiography / Q000379:methods*; D003914:Dextrocardia / Q000150:complications* / Q000175:diagnosis; D004452:Echocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011651:Pulmonary Artery / Q000000981:diagnostic imaging*; D011655:Pulmonary Embolism / Q000097:blood / Q000150:complications* / Q000175:diagnosis; D012720:Severity of Illness Index