This is the first study to show that plasma BNP levels seem to predict adverse outcome in patients with acute pulmonary embolism.

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Summary. Background: Clinicians often deviate from the recommended algorithm for the diagnosis of pulmonary embolism consisting of ventilation-perfusion scintigraphy and pulmonary angiography. Objectives: To assess the safety and feasibility of a diagnostic algorithm which reduces the need for lung scintigraphy and avoids the use of angiography. Patients and methods: Consecutive patients with a clinical suspicion of pulmonary embolism were prospectively investigated according to an algorithm in which the diagnosis of pulmonary embolism was excluded after a low clinical probability estimate and a normal D-dimer test result, a normal perfusion scintigraphy result, or a non-high probability scintigraphy result in combination with normal serial ultrasonography of the legs. In these patients anticoagulant treatment was withheld and they were followed up for 3 months to record possible thromboembolic events. During the study period, 923 consecutive patients were seen, of whom 292 were excluded because of predefined criteria. Results: Of the 631 included patients, the diagnosis was refuted on the basis of a low clinical probability estimate and a normal D-dimer test result (95 patients), normal perfusion scintigraphy (161 patients) and non-high probability lung scintigraphy followed by normal serial ultrasonography (210 patients). Of these 466 patients, venous thromboembolic complications during follow-up occurred in six (complication rate 1.3%, 95% confidence interval 0.5, 2.8). The diagnostic protocol was completed in 92% of all included patients. Conclusion: The diagnosis of pulmonary embolism can be safely ruled out by a non-invasive algorithm consisting of D-dimer testing combined with a clinical probability estimate, lung scintigraphy, or serial ultrasonography of the legs (in case of non-diagnostic lung scintigraphy).

To cite this article: Douketis JD, Leeuwenkamp O, Grobara P, Johnston M, Sö hne M, ten Wolde M, Bü ller H. The incidence and prognostic significance of elevated cardiac troponins in patients with submassive pulmonary embolism. J Thromb Haemost 2005; 3: 508-13.Summary. Although the incidence and prognostic significance of elevated cardiac troponins are known in patients with massive pulmonary embolism (PE), few studies have addressed this issue in patients with hemodynamically stable, submassive PE, who comprise the majority of patients presenting with PE. This prospective cohort study was, therefore, designed to determine the incidence and prognostic significance of elevated cardiac troponins in patients with submassive PE. Consecutive patients with acute, symptomatic, submassive PE that was confirmed by objective diagnostic testing were studied. All patients received treatment with either unfractionated heparin or fondaparinux followed by a coumarin derivative and underwent clinical follow-up for 3 months. Cardiac troponin I (cTnI) levels were measured within 24 h of clinical presentation. An elevated cTnI was defined as > 0.5 lg L )1 and indicated myocardial injury.Major myocardial injury, that is associated with myocardial infarction, was defined by a cTnI > 2.3 lg L )1. The clinical outcomes were recurrent venous thromboembolism and allcause death. In 458 patients with submassive PE, the incidence of cTnI > 0.5 lg L )1 was 13.5% [95% confidence interval (CI):10. 4-16.7], and the incidence of cTnI > 2.3 lg L )1 was 3.5% (95% CI: 2.0-5.6). An elevated cTnI > 0.5 lg L )1 was associated with an increased risk of all-cause death [odds ratio (OR) ¼ 3.5; 95% CI: 1.0-11.9], but did not appear to confer an increased risk of recurrent venous thromboembolism (OR ¼ 1.1; 95% CI: 0.2-4.9). In patients who present with submassive PE, an elevated cTnI occurs in about one in seven patients and is associated with a 3.5-fold increased risk of all-cause death.

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