Prognostic Role of Right Ventricular Dilatation and Troponin I Elevation in Acute Pulmonary Embolism

Abstract

SUMMARYAcute pulmonary embolism continues to cause significant morbidity and mortality despite advances in diagnosis and treatment. This retrospective analysis aimed to determine whether the combination of elevated troponin I and right ventricular dilatation (RVD) could provide a more powerful predictor for risk evaluation.The study data comprised records of 110 patients with either high-probability ventilation/perfusion lung scan or positive spiral computed tomography. All cause 100-day mortality was 18.2%. The hypotension and RVD variables significantly influenced 100-day mortality. For the combination of RVD and raised troponin I, the 100-day mortality rate was 31%. Notably, the group with elevated troponin I and no RVD had a 100-day mortality rate of only 3.7%. The combination of RVD and elevated troponin had a positive predictive value of 31% and a negative predictive value of 88% for 100-day mortality. Compared with existing reports, conflicting conclusions for the individual prognostic role of elevated troponin I, cancer, and heart failure were obtained. These conflicting conclusions most likely resulted from inappropriate cut-off troponin I values and the modest sample size.In conclusion, the combination of elevated troponin and RVD was able to identify a subset of patients most likely to benefit from aggressive therapy. (Int Heart J 2006; 47: 775-781) Key words: Pulmonary embolism, Right ventricular dilatation, Troponin I PULMONARY embolism (PE) remains a major cause of morbidity and mortality among the general population, with an estimated incidence of 0.5 per 1000 people 1) and a case-fatality rate of 15% at 3 months.2) Patients with pulmonary embolism present with a wide range of clinical acuity, thus necessitating different therapeutic strategies. Shock or systemic hypotension with systolic BP < 90 mmHg are the generally accepted indications for urgent thrombolysis in patients with acute PE.

Prognostic Value of Troponins in Acute Pulmonary Embolism

“…19,20,27,28 The main features of the selected studies are reported in Table 1. Demographic features of study populations (age, gender) were similar across the studies, and almost all the included patients had an objective diagnosis of pulmonary embolism.…”

“…In 2 studies, mortality was available only at 90 days 24,26 ; in a third study, mortality was available only at 100 days. 28 …”

“…Overall, 40 events were observed: 34 in 207 patients with elevated troponin (16.4%; 95% CI, 11.4 to 21.4) and 6 in 438 with normal troponin levels (1.4%; 95% CI, 0.8 to 1.9). 10,12,15,18,21,22,24,28 Elevated troponin levels were associated with a high risk of death resulting from pulmonary embolism (OR, 9.44; 95% CI, 4.14 to 21.49) (Figure 3). …”

“…Analysis of 3 of these studies 10,20,28 showed an independent prognostic value for elevated troponin levels (Pϭ0.01) and right ventricular dysfunction at echocardiography (Pϭ0.005), with no evidence for interaction (Pϭ0.29).…”

Elevated Cardiac Biomarkers With Normal Right Ventricular Size Indicate an Unlikely Diagnosis of Acute Pulmonary Embolism in Stable Patients

“…Others described this combination among unstable as well as stable patients. 4,20,[22][23][24][25][26][27] We were unable to identify investigations of patients with PE in which levels of cTnI consistent with acute myocardial infarction in combination with RV size were described.…”