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Internal and Emergency Medicine

, Volume 3, Issue 2, pp 131–138 | Cite as

Troponin I and right ventricular dysfunction for risk assessment in patients with nonmassive pulmonary embolism in the Emergency Department in combination with clinically based risk score

  • Vittorio PalmieriEmail author
  • Giovanni Gallotta
  • Domenico Rendina
  • Silvana De Bonis
  • Vittorio Russo
  • Alfredo Postiglione
  • Stefania Martino
  • Matteo Nicola Dario Di Minno
  • Aldo Celentano
EM - Original

Abstract

To determine whether troponin I (cTnI) and right ventricular (RV) dysfunction predict adverse in-hospital outcomes in patients admitted to the Emergency Department (ED) with definite nonmassive pulmonary embolism (PE) independent of and in addition to a recently validated clinical prognostic risk score. From a pool of 168 patients with suspected PE, 89 had nonmassive PE confirmed by spiral lung angio-computed tomography. By the clinical prognostic score, in our study sample, 14% had very low risk; 17% had low risk, 20% had intermediate risk, whereas high risk and very high risk were identified in 29 and 20%, respectively. Prevalence of elevated cTnI (>0.1 μg/L, 57%) at admission was comparable among patients grouped by clinical prognostic score (P = NS); echocardiographic RV dysfunction (54%) was more prevalent with intermediate or high clinical risk score (P < 0.02). Increased cTnI predicted primary end-point (development of hemodynamic instability, overall 33 cases, 37%) independent of and in addition to the clinical risk class and RV dysfunction (P < 0.01 for interaction). Fatal events (12 cases, 14%, 5 definite, 7 possible PE-related) were predicted by higher clinical risk score (P < 0.05). In patients with nonmassive central PE admitted to the ED, increased cTnI contributed to identifying those with increased risk of development of hemodynamic instability independent of and in addition to a validated clinically based risk score.

Keywords

Pulmonary embolism Troponin Prognosis Echocardiography 

Notes

Conflict of interest

No author has conflict of interest to disclose.

References

  1. 1.
    Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology (2000) Eur Heart J 21:1301–1336Google Scholar
  2. 2.
    Piazza G, Goldhaber SZ (2006) Acute pulmonary embolism: part II: treatment and prophylaxis. Circulation 114:e42–e47PubMedCrossRefGoogle Scholar
  3. 3.
    Becattini C, Vedovati MC, Agnelli G (2007) Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 116:427–433PubMedCrossRefGoogle Scholar
  4. 4.
    Goldhaber SZ, Elliott CG (2003) Acute pulmonary embolism: part II: risk stratification, treatment, and prevention. Circulation 108:2834–2838PubMedCrossRefGoogle Scholar
  5. 5.
    Goldhaber SZ, Elliott CG (2003) Acute pulmonary embolism: part I: epidemiology, pathophysiology, and diagnosis. Circulation 108:2726–2729PubMedCrossRefGoogle Scholar
  6. 6.
    Goldhaber SZ (2004) Pulmonary embolism. Lancet 363:1295–1305PubMedCrossRefGoogle Scholar
  7. 7.
    La Vecchia L, Ottani F, Favero L, Spadaro GL, Rubboli A, Boanno C, Mezzena G, Fontanelli A, Jaffe AS (2004) Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism. Heart 90:633–637PubMedCrossRefGoogle Scholar
  8. 8.
    Douketis JD, Leeuwenkamp O, Grobara P, Johnston M, Sohne M, Ten Wolde M, Buller H (2005) The incidence and prognostic significance of elevated cardiac troponins in patients with submassive pulmonary embolism. J Thromb Haemost 3:508–513PubMedCrossRefGoogle Scholar
  9. 9.
    Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H (1997) Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 77:346–349PubMedGoogle Scholar
  10. 10.
    Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, Conti A, Agnelli G, Berni G (2000) Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 101:2817–2822PubMedGoogle Scholar
  11. 11.
    Kucher N, Wallmann D, Carone A, Windecker S, Meier B, Hess OM (2003) Incremental prognostic value of troponin I and echocardiography in patients with acute pulmonary embolism. Eur Heart J 24:1651–1656PubMedCrossRefGoogle Scholar
  12. 12.
    Pruszczyk P, Bochowicz A, Torbicki A, Szulc M, Kurzyna M, Fijalkowska A, Kuch-Wocial A (2003) Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism. Chest 123:1947–1952PubMedCrossRefGoogle Scholar
  13. 13.
    Aujesky D, Roy PM, Le Manach CP, Verschuren F, Meyer G, Obrosky DS, Stone RA, Cornuz J, Fine MJ (2006) Validation of a model to predict adverse outcomes in patients with pulmonary embolism. Eur Heart J 27:476–481PubMedCrossRefGoogle Scholar
  14. 14.
    Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, Roy PM, Fine MJ (2005) Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 172:1041–1046PubMedCrossRefGoogle Scholar
  15. 15.
    Aksay E, Yanturali S, Kiyan S (2007) Can elevated troponin I levels predict complicated clinical course and inhospital mortality in patients with acute pulmonary embolism? Am J Emerg Med 25:138–143PubMedCrossRefGoogle Scholar
  16. 16.
    Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A (2001) Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 161:92–97PubMedCrossRefGoogle Scholar
  17. 17.
    Rodger M, Wells PS (2001) Diagnosis of pulmonary embolism. Thromb Res 103:V225–V238PubMedCrossRefGoogle Scholar
  18. 18.
    McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT (1996) Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 78:469–473PubMedCrossRefGoogle Scholar
  19. 19.
    Raschke RA, Reilly BM, Guidry JR, Fontana JR, Srinivas S (1993) The weight-based heparin dosing nomogram compared with a “standard care” nomogram. A randomized controlled trial. Ann Intern Med 119:874–881PubMedGoogle Scholar
  20. 20.
    Gallotta G, Palmieri V, Piedimonte V, Rendina D, De Bonis S, Russo V, Celentano A, Di Minno MN, Postiglione A, Di Minno G (2007) Increased troponin I predicts in-hospital occurrence of hemodynamic instability in patients with sub-massive or non-massive pulmonary embolism independent to clinical, echocardiographic and laboratory information. Int J Cardiol [E-pub ahead of print March 23]Google Scholar
  21. 21.
    Logeart D, Lecuyer L, Thabut G, Tabet JY, Tartiere JM, Chavelas C, Bonnin F, Stievenart JL, Solal AC (2007) Biomarker-based strategy for screening right ventricular dysfunction in patients with non-massive pulmonary embolism. Intensive Care Med 33:286–292PubMedCrossRefGoogle Scholar
  22. 22.
    Dawson D, Trapp RG (2004) Analyzing research questions about survival. In: Dawson D, Trapp RG (eds) Basic and cliniucal biostatistics. McGraw-Hill, New York, pp 221–241Google Scholar
  23. 23.
    Binder L, Pieske B, Olschewski M, Geibel A, Klostermann B, Reiner C, Konstantinides S (2005) N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 112:1573–1579PubMedCrossRefGoogle Scholar
  24. 24.
    Kostrubiec M, Pruszczyk P, Bochowicz A, Pacho R, Szulc M, Kaczynska A, Styczynski G, Kuch-Wocial A, Abramczyk P, Bartoszewicz Z, Berent H, Kuczynska K (2005) Biomarker-based risk assessment model in acute pulmonary embolism. Eur Heart J 26:2166–2172PubMedCrossRefGoogle Scholar

Copyright information

© SIMI 2008

Authors and Affiliations

  • Vittorio Palmieri
    • 1
    • 2
    Email author
  • Giovanni Gallotta
    • 2
  • Domenico Rendina
    • 3
  • Silvana De Bonis
    • 3
  • Vittorio Russo
    • 3
  • Alfredo Postiglione
    • 2
  • Stefania Martino
    • 2
  • Matteo Nicola Dario Di Minno
    • 2
  • Aldo Celentano
    • 1
    • 2
  1. 1.Cardiology Unit“Ospedale dei Pellegrini”NaplesItaly
  2. 2.Department of Clinical and Experimental Medicine“Federico II” University Hospital, University of Naples-School of MedicineNaplesItaly
  3. 3.Department of Emergency Medicine“Antonio Cardarelli” HospitalNaplesItaly

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