Prognostic Value of Plasma Lactate Levels Among Patients With Acute Pulmonary Embolism (TELOS)

February 15, 2014 updated by: Peiman Nazerian, Azienda Ospedaliero-Universitaria Careggi

Prognostic Value of Plasma Lactate Levels Among Patients With Acute Pulmonary Embolism: the Thrombo-Embolism Lactate Outcome Study

To prospectively investigate the association between plasma lactate concentration and short-term adverse outcomes in patients with acute PE.

Study Overview

Status

Completed

Conditions

Detailed Description

Pulmonary embolism (PE) represents 0.4% of hospitalizations and is the third leading cause of death due to cardiovascular disease (1). In contrast to stroke and acute coronary syndromes, its mortality has not decreased in recent decades likely due to only minor advances in short-term prognostication and treatment strategies (2).The presence of shock or hypotension remains the principal prognostic clinical marker and,to date, is the only factor that clearly indicates a more aggressive treatment than heparin (3). However, only 5% of patients with acute PE present with shock. The majority of PE patients are normotensive and are usually treated with heparin alone. Several studies have looked for new prognostic indicators in order to better stratify normotensive PE patients. A large body of evidence shows that right ventricular dysfunction/injury markers such as elevation of brain natriuretic peptides, troponins, and echocardiographic evidence of right ventricular dysfunction (RVD) are associated with adverse prognosis (3-8). However, these markers have some important limitations. Echocardiography is usually not available around-the-clock in most clinical settings, moreover it shares with troponins and natriuretic peptides a good negative predictive value (>90%) but a low positive predictive value (about 10%) for short-term mortality, probably precluding these markers' usefulness to target more aggressive treatments (8).

Plasma lactate concentration is a marker of the severity of the tissue oxygen supply-to-demand imbalance. It may reflect tissue hypoperfusion also in the presence of normal blood pressure. Accordingly, in other critical settings such as sepsis,plasma lactate concentration is considered to be an accurate prognostic marker as it rises before hemodynamic impairment is clinically evident (9). Furthermore, plasma lactate concentration can be easily and rapidly assayed on arterial blood samples using a blood gas analyzer, which is usually available in emergency departments (EDs) and intensive care units. Recently, a retrospective study showed that plasma lactate ≥ 2 mmol/L was associated with a high mortality rate in patients with acute PE (10). Moreover a prospective monocentric study confirmed these retrospective results and revealed that plasma lactate has prognostic relevance beyond known clinical and instrumental prognostic markers (TELOS study, Ann Emerg Med, in press, see attached file)

The aim of present study is to prospectively investigate the association between plasma lactate concentration and short-term adverse outcomes in patients with acute PE. In particular, we examine whether high plasma lactate (≥ 2 mmol/L) is associated with a high incidence of PE related major adverse events, defined as PE related death or hemodynamic collapse >10% within 7 days of follow-up. Moreover we investigate whether plasma lactate shows incremental prognostic value to clinically overt hemodynamic impairment and to RVD/injury markers, maintaining prognostic relevance in both hypotensive and normotensive PE patients.

Study Type

Observational

Enrollment (Anticipated)

330

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Italy
      • Florence, Italy, 50134
        • Azienda Ospedaliero Universitaria Careggi, Emergency Department
      • Livorno, Italy
        • Presidio Ospedaliero Livorno
      • Torino, Italy
        • Azienda ospedaliera universitaria San Giovanni Battista (Molinette)
  • Spain
      • Madrid, Spain
        • Respiratory Department and Medicine Department, Ramón y Cajal Hospital and Alcalá de Henares University

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Sampling Method

Probability Sample

Study Population

Consecutive adult patients (minimum age eighteen) who presented to the ED of the hospitals participating in the study with clinical suspicion of PE will be considered for the study. We excluded patients with life expectancies of less than 3 months, and patients with first symptoms 15 day or more before inclusion.

The diagnosis of PE will be established by spiral computed tomography or by lung scan or a selective pulmonary angiogram.

Patients with proven PE who will give written consent to the use of their medical information for research purposes will be enrolled in the study.

Description

Inclusion Criteria:

  • Symptomatic objective pulmonary embolism

Exclusion Criteria:

  • life expectancies of less than 3 months
  • first symptoms 15 day or more before inclusion.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Cohorts and Interventions

Group / Cohort
Pulmonary Embolism
Consecutive adult patients (minimum age eighteen) who presented to the ED of the hospitals participating in the study with clinical suspicion of PE will be considered for the study. We excluded patients with life expectancies of less than 3 months, and patients with first symptoms 15 days or more before inclusion.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
The composite of PE related death or hemodynamic collapse
Time Frame: 7 days.

PE related death was defined as a fatal event occurring in the hours after clinical deterioration due to PE, including an objectively diagnosed recurrent PE, or if death could not be attributed to a documented cause and PE could not be confidently ruled out. Autopsy is not mandatory.

Hemodynamic collapse is defined as at least 1 of the following: (i) the need for cardiopulmonary resuscitation; (ii) systolic blood pressure <90 mm Hg for at least 15 minutes, or drop of systolic blood pressure by at least 40 mm Hg for at least 15 minutes, with signs of end-organ hypoperfusion (cold extremities, or urinary output <30 mL/h, or mental confusion); (iii) the need for catecholamines (except for dopamine at a rate of < 5 μg kg-1 min-1) to maintain adequate organ perfusion and a systolic blood pressure of >90 mm Hg; (iiii) the need for invasive or noninvasive mechanical ventilation; (iiiii) imaging-confirmed symptomatic recurrence of PE within 7 days.
7 days.

Secondary Outcome Measures

Outcome Measure
Time Frame
PE recurrence
Time Frame: 30 days
30 days
all cause death
Time Frame: 30 days
30 days

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Azienda Ospedaliero-Universitaria Careggi

Investigators

  • Study Chair: Stefano Grifoni, MD, Emergency department, Azienda Ospedaliero Universitaria Careggi

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

December 1, 2012

Primary Completion (Actual)

January 1, 2014

Study Completion (Actual)

February 1, 2014

Study Registration Dates

First Submitted

July 23, 2013

First Submitted That Met QC Criteria

July 23, 2013

First Posted (Estimate)

July 25, 2013

Study Record Updates

Last Update Posted (Estimate)

February 19, 2014

Last Update Submitted That Met QC Criteria

February 15, 2014

Last Verified

February 1, 2014

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 0313

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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