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.

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Proximal pulmonary emboli modify right ventricular ejection pattern. A. Torbicki, M. Kurzyna, M. Ciurzynski, P. Pruszczyk, R. Pacho, A. Kuch-Wocial, M. Szulc. #ERS Journals Ltd 1999. ABSTRACT: Analysis of the systolic flow velocity curve (SFVC) in the right ventricular outflow tract is considered as an alternative to the tricuspid valve pressure gradient (TVPG) method for echo-Doppler assessment of pulmonary arterial pressure (Ppa). The present study checked whether or not SFVC is affected by the cause of pulmonary hypertension.Doppler recordings of 86 patients (39 female, aged 55.515.2 yrs) with acute (AP-PE) or chronic (CP-PE) proximal pulmonary embolism, chronic obstructive pulmonary disase (COPD) or primary pulmonary hypertension (PPH) were retrospectively analysed by two observers unaware of the purpose of the study.Despite having the lowest TVPG (4813 mmHg), patients with AP-PE had the shortest acceleration time (tacc; 5615 ms) and time to midsystolic deceleration (tmsd; 10516 ms). tacc <60 ms in patients with TVPG <60 mmHg had 98% specificity and 48% sensitivity for AP-PE. In PPH, SFVC was less abnormal (tacc 6414 ms, tmsd 12525 ms, both p<0.03) despite having a TVPG twice as high (9212 mmHg, p< 0.001). In contrast to tacc, TVPG showed strong correlation with direct Ppa measurements whenever performed (r=-0.43, p=0.02, versus r=0.80, p<0.001; n=30). There was no correlation between tacc and TVPG in a pooled study group and SFVC seemed strongly affected by the presence of both AP-PE and CP-PE.While potentially useful for evaluation of the true right ventricular afterload during pulsatile flow conditions, the systolic flow velocity curve does not provide a reliable estimate of pulmonary arterial pressure. Eur Respir J 1999; 13: 616±621. The method of choice for noninvasive estimation of pulmonary arterial pressure (Ppa) is based on continuous wave Doppler measurement of the peak velocity of the regurgitant jet across the tricuspid valve (tricuspid valve pressure gradient; TVPG). This method, based on the simplified Bernoulli equation and a straightforward pathophysiological concept, proved highly reliable in a wide spectrum of cardiovascular disease [1±4].However, the pulsed wave Doppler-derived pattern of the systolic flow velocity curve (SFVC) in the right ventricular (RV) outflow tract is also believed to reflect the level of Ppa [5±9]. Using SFVC is appealing because, in contrast to TVPG, it can be recorded in almost every patient, including those with lung hyperinflation [10]. Coexistence of short acceleration time (tacc) and midsystolic deceleration (tmsd; which has a "notched" pattern) is considered diagnostic of severe pulmonary hypertension [5]. However, such patterns have also been observed in the setting of acute pulmonary embolism [11] and similar changes have been induced experimentally by proximal constriction of the proximal pulmonary arteries in dogs [12]. In both these situations, marked SFVC changes were found in the presence of acute but relatively mild elevation of Ppa limited by the per...

Current knowledge of pulmonary arterial hypertension (PAH) epidemiology is based mainly on data from Western populations, and therefore we aimed to characterize a large group of Caucasian PAH adults of Central-Eastern European origin. We analyzed data of incident and prevalent PAH adults enrolled in a prospective national registry involving all Polish PAH centers. The estimated prevalence and annual incidence of PAH were 30.8/mln adults and 5.2/mln adults, respectively and they were the highest in females ≥65 years old. The most frequent type of PAH was idiopathic (n = 444; 46%) followed by PAH associated with congenital heart diseases (CHD-PAH, n = 356; 36.7%), and PAH associated with connective tissue disease (CTD-PAH, n = 132; 13.6%). At enrollment, most incident cases (71.9%) were at intermediate mortality risk and the prevalent cases had most of their risk factors in the intermediate or high risk range. The use of triple combination therapy was rare (4.7%). A high prevalence of PAH among older population confirms the changing demographics of PAH found in the Western countries. In contrast, we found: a female predominance across all age groups, a high proportion of patients with CHD-PAH as compared to patients with CTD-PAH and a low use of triple combination therapy.

of renal dysfunction improves troponin-based short-term prognosis in patients with acute symptomatic pulmonary embolism. J Thromb Haemost 2010; 8: 651-8.Summary. Objective: Current risk stratification in acute pulmonary embolism (APE) includes assessment of clinical status, right ventricular overload and plasma troponin concentrations. As impaired renal function is one of the important predictors of mortality in cardiovascular diseases, we hypothesized that it is an independent early mortality marker in APE. Material and methods: In prospective cohort study, we observed 220 consecutive patients (86M/134F, 64 ± 18 years) with APE proven by spiral computed tomography (CT). On admission, echocardiography was performed and blood samples were collected for troponin and creatinine assays. Results: The calculated glomerular filtration rate (GFR) differed significantly between 81 pts with low-, 131 pts with moderate-and 8 pts with high-risk APE [71 (19-181) vs. 55 (9-153) vs. 41 (14-68) mL min )1 ; respectively P < 0.0001]. Twenty-three patients died during the 30-day observation. Importantly, GFR was lower in non-survivors than in survivors [35 (9-92) vs. 63 (14-181) mL min )1 , P < 0.0001]. The area under the curve (AUC) of the GFR receiver-operating characteristic (ROC) curve for predicting mortality was 0.760 (95% CI: 0.698-0.815). In multivariable analysis, independent mortality predictors were GFR, troponin, heart rate and history of chronic heart failure. In normotensive patients, the GFR and cardiac troponins (cTn) ROC curves for prediction of mortality showed no difference (AUC 0.789 and 0.781, respectively). However, Kaplan-Meier analysis showed an additive prognostic value of renal dysfunction. Thus, troponin-positive patients with a GFR £ 35 mL mn )1 showed 48% 30-day mortality, whereas troponin-positive patients with a GFR > 35 mL mn )1 had 11% mortality, and troponin-negative patients with a GFR > 35 mL mn )1 had good prognosis, P < 0.0001. Conclusion: Impaired kidney function, present in 47% of APE patients, is related to all-cause mortality. In initially normotensive patients, a GFR < 35 mL min )1 predicts 30-day mortality. Moreover, GFR assessment can improve troponin-based risk stratification of APE.