Prognostic value of echocardiography in normotensive patients with acute pulmonary embolism
Piotr Pruszczyk, Sylwia Goliszek, Barbara Lichodziejewska, Maciej Kostrubiec, Michał Ciurzyński, Katarzyna Kurnicka, Olga Dzikowska-Diduch, Piotr Palczewski, Anna Wyzgal, Piotr Pruszczyk, Sylwia Goliszek, Barbara Lichodziejewska, Maciej Kostrubiec, Michał Ciurzyński, Katarzyna Kurnicka, Olga Dzikowska-Diduch, Piotr Palczewski, Anna Wyzgal
Abstract
Objectives: The goal of the study was to evaluate the prognostic value of echocardiographic indices of right ventricular dysfunction (RVD) for prediction of pulmonary embolism-related 30-day mortality or need for rescue thrombolysis in initially normotensive patients with acute pulmonary embolism (APE).
Background: There is no generally accepted echocardiographic definition of RVD used for prognosis in APE.
Methods: We studied the prognostic value of a set of echocardiographic parameters in 411 consecutive patients (234 women, age 64 ± 18 years) with APE hemodynamically stable at admission.
Results: Thirty-day APE-related mortality was 3% (14 patients), all-cause mortality was 5% (21 patients). Nine patients received thrombolysis as a result of hemodynamic deterioration, and 7 of them survived. The clinical endpoint (CE), which included APE-related death or thrombolysis, occurred in 21 patients. At univariable Cox analysis, the hazard ratio (HR) for CE of the right ventricular (RV)/left ventricular (LV) ratio was 7.3 (95% confidence interval [CI]: 2.0 to 27.3; p = 0.003). However, multivariable analysis showed that tricuspid annulus plane systolic excursion (TAPSE) was the only independent predictor (HR: 0.64, 95% CI: 0.54 to 0.7; p < 0.0001). Moreover, the area under the curve (AUC) in receiver-operating characteristic analysis for TAPSE (0.91, 95% CI: 0.856 to 0.935; p = 0.0001) in CE prediction was higher (p < 0.001) than AUC of RV/LV ratio (0.638, 95% CI: 0.589 to 0.686; p = 0.001). TAPSE ≤15 mm had a HR of 27.9 (95% CI: 6.2 to 124.6; p < 0.0001) and a positive predictive value (PPV) of 20.9% for CE with a 99% negative predictive value (NPV), whereas TAPSE ≤20 mm had a PPV of 9.2 with a 100% NPV. RV/LV ratios of >0.9 and >1.0 had a PPV of 13.2% and 14.4% and a NPV of 97% and 94.3%, respectively.
Conclusions: TAPSE is preferable to the RV/LV ratio for risk stratification in initially normotensive patients with APE. TAPSE ≤15 mm identifies patients with an increased risk of 30-day APE-related mortality, whereas TAPSE >20 mm can be used for identification of a very low-risk group.
Keywords: echocardiography; prognosis; pulmonary embolism.
Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Source: PubMed