Prognostic significance of computed tomography-assessed right ventricular enlargement in low-risk patients with pulmonary embolism: Systematic review and meta-analysis

Andrade, Isabel; Mehdipoor, Ghazaleh; Mao, Raphaël Le; García‐Sánchez, Aldara; Pintado, Beatriz; Pérez, Andrea; Rodrı́guez, Carmen; Velasco, Diurbis; Bikdeli, Behnood; Jiménez, David

doi:10.1016/j.thromres.2020.10.034

Cited by 11 publications

(6 citation statements)

References 34 publications

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“…Prior studies showed no significant difference in all-cause mortality or adverse events within 30 days in patients classified as low risk by sPESI with abnlRV assessment on CT imaging. 36,40 We found that in a univariate F I G U R E 3 Interaction between GDE score and CT RV:LV ratio on predictive accuracy of 5-day clinical deterioration case, CT RV:LV ratio has a 4.51-and 1.62-fold increased risk of CD at 5 days and 30 days, respectively. This significant relationship is upheld in the multivariable logistic regression model in an interaction with GDE score.…”

Section: Discussionmentioning

confidence: 77%

Can right ventricular assessments improve triaging of low risk pulmonary embolism?

Raper

Thomas

Lupez

et al. 2022

Academic Emergency Medicine

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Objectives Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the Simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to (1) determine if RV assessment variables add prognostic accuracy for 5‐day clinical deterioration in patients classified low risk by sPESI, and (2) determine the prognostic importance of RV assessments compared to other variables and to each other. Methods We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed, and compared prognostic accuracy of, full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE. Results Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by CT, 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77–0.82) and 0.71 (0.68–0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5‐day clinical deterioration by the multivariable logistic regression. Conclusions A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5‐day clinical deterioration versus one without.

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Section: Discussionmentioning

confidence: 77%

Can right ventricular assessments improve triaging of low risk pulmonary embolism?

Raper

Thomas

Lupez

et al. 2022

Academic Emergency Medicine

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“…Clinical algorithms, checklists, and prognostic models are being developed and updated to optimize the safety of outpatient management, improve prognostic accuracy for outcome(s), and provide guidance to reduce practice variation. Incorporation of imaging and laboratory assessments for PE-provoked abnlRV have now been incorporated into hybrid clinical algorithms [1,7,[13][14][15][16], and some meta-analyses now support use of one or multiple RV assessment methods [4,17,18]. A consistent definition of PE-provoked abnlRV, however, is lacking [19][20][21][22].…”

Section: Introductionmentioning

confidence: 99%

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE)

et al. 2021

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Objective Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. Methods We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). Results Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. Conclusions PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.

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“…In addition to its fundamental role in the diagnosis of PE with a sensitivity of 83% and a specificity of 96%, computed tomographic pulmonary angiography is also useful in assessing the extent of pulmonary vascular damage, allowing adequate visualization of the pulmonary arteries down to the subsegmental level, as well as identifying chronic thromboembolic pulmonary hypertension (CTEPH), a potentially fatal late sequela of PE [38][39][40]. On acute low-risk PE, a recent meta-analysis showed computed tomography-assessed RV enlargement was present in 34% of subjects, with higher 30-day mortality (OR 2.6) [41]. In our study, we observed that the group of patients with sST2 values >35 ng/mL (the threshold recognized as predictive of acute cardiac complications [42]) showed the most extended embolic occlusion of pulmonary arteries (20% for massive PE and 47% submassive PE), compared with the group with values less than 35 ng/mL (50% submassive PE, no massive PE); these findings confirmed the meaningful correlation between circulating levels of sST2 and the extension of damage in the pulmonary arterial circulation, suggesting the useful role of ST2 evaluation in highlighting the grade of vascular pulmonary involvement.…”

Section: Discussionmentioning

confidence: 99%

Assessment of sST2 Behaviors to Evaluate Severity/Clinical Impact of Acute Pulmonary Embolism

Petramala

Concistrè

Sarlo

et al. 2023

IJMS

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Pulmonary embolism (PE) is a potentially life-threatening disorder. Beyond its usefulness in the prognostic stratification of heart failure, sST2 can represent a biomarker with high utility in several acute conditions. Our study was aimed to investigate whether sST2 can be used as a clinical marker of severity and prognostic outcome in acute PE. We enrolled 72 patients with documented PE and 38 healthy subjects; we measured the plasma concentrations of sST2 to evaluate the prognostic and severity performance of different levels of sST2 according to its association with the pulmonary embolism severity index (PESI) score and several parameters of respiratory function. PE patients had significantly higher levels of sST2 compared with healthy subjects (87.74 ± 17.1 vs. 17.1 ± 0.4 ng/mL, p < 0.001); we found higher PESI scores and serum lactate values in the group of patients with sST2 > 35 ng/mL compared with patients with sST2 < 35 ng/mL (138.7 ± 14.9 vs. 103.7 ± 15.1 and 2.43 ± 0.69 vs. 1.025 ± 0.05 mmol/L, respectively; p < 0.05). Patients with sST2 > 35 ng/mL showed higher radiological severity of PE compared with patients with sST2 < 35 ng/mL. Moreover, sST2 was the strongest parameter with a discriminative capacity for the development of acute respiratory failure and a PESI score >106 with respect to C reactive protein (CRP), creatinine, d-dimer, and serum lactate. We clearly demonstrated that sST2 significantly increased in PE and that its elevation was associated with disease severity. Therefore, sST2 may be used as a clinical marker in the evaluation of PE severity. However, further studies with larger patient populations are required to confirm these findings.

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Prognostic significance of computed tomography-assessed right ventricular enlargement in low-risk patients with pulmonary embolism: Systematic review and meta-analysis

Cited by 11 publications

References 34 publications

Can right ventricular assessments improve triaging of low risk pulmonary embolism?

Can right ventricular assessments improve triaging of low risk pulmonary embolism?

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE)

Assessment of sST2 Behaviors to Evaluate Severity/Clinical Impact of Acute Pulmonary Embolism

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