Prognostic Value of Echocardiography in Normotensive Patients With Acute Pulmonary Embolism
Article: Pruszczyk P, et. al. Prognostic value of echocardiography in normotensive patients with acute pulmonary embolism. JACC Cardiovasc Imaging. 2014 Jun;7(6):553-60. doi: 10.1016/j.jcmg.2013.11.004.
Overview: Echocardiographic evidence of right ventricular dysfunction (RVD) in acute pulmonary embolism (APE) has significance prognostic value. Right ventricular enlargement is found in approximately 30% of normotensive hemodynamically stable patients with APE and as a sign of RVD and injury, is a predictor of poor clinical outcome. The mortality rate reported
in these patients with RVD diagnosed according to different echocardiographic criteria varied markedly from 4.3% up to 16.4%. Given there was no direct comparison of echocardiographic criteria for short-term risk prognosis in APE available, this study analyzed the prognostic value of echocardiographic parameters of RVD for prediction of PE-related 30-day mortality or need for rescue thrombolysis in initially normotensive patients with APE.
Methods: The prospective observational cohort study looked at the echocardiographic findings of 411 consecutive patients (234 women, age 46-81 years) with symptomatic APE who were hemodynamically stable at admission. Most echocardiography was performed immediately on admission and within 24 hours. The test was performed and interpreted according to a standardized protocol by an experienced physician. PE was then confirmed using contrast-enhanced CT. The clinical endpoint of the study was defined as at least one for the following:
1. The need for cardiopulmonary resuscitation.
2. Systolic blood pressure below 90 mm Hg for at least 15 min, with signs of end-organ hypoperfusion.
3. The need for pressors
Results: From the 411 patients in the study, 241 (58.6%) had a submassive APE, of which 9 (3.7%) received urgent thrombolysis. The 30-day APE-related mortality was 3% and all-cause mortality was 5%, with the clinical endpoint (CE) observed in 21 patients. Approximately all echocardiographic parameters assessing the RV, except for two, indicated more significant RV impairment in patients with CE than in patients with an uncomplicated clinical course. RV/LV ratio of 0.9-1 measured in the apical 4-chamber view showed the highest hazard ratio (HR) for APE related mortality or rescue thrombolysis (HR: 7.3). However, a multivariable analysis showed that TAPSE was the only independent predictor of 30-day PE-related mortality or thrombolysis. TAPSE 15 mm had a HR of 27.9 and a PPV of 20.9% for CE with a 99% NPV, whereas TAPSE 20 mm had a PPV of 9.2 with a 100% NPV.
Takeaway: There are multiple echocardiographic indicators used to diagnose RVD in APE and this study found TAPSE to be the most valuable predictor of clinical course among them. TAPSE is an easy to measure and well-known parameter that reflects global systolic RV function and therefore can be easily and accurately reproduced. Given the results of this study, TAPSE should be used to risk stratify these patients, therefore contributing to clinical decision making. A TAPSE 15 mm identifies patients with an increased risk of 30-day APE-related mortality, whereas TAPSE >20 mm can be used to identify a very low-risk group.
Post by Gabriella Lopes, MS4