Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
  • Alerts
  • Subscriptions

Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?

R. Otero, J. Trujillo-Santos, A. Cayuela, C. Rodríguez, M. Barron, J. J. Martín, M. Monreal and the Registro Informatizado de la Enfermedad Tromboembólica (RIETE) Investigators
European Respiratory Journal 2007 30: 1111-1116; DOI: 10.1183/09031936.00071007
R. Otero
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
J. Trujillo-Santos
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
A. Cayuela
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
C. Rodríguez
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
M. Barron
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
J. J. Martín
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
M. Monreal
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Patients with acute pulmonary embolism (PE) presenting with haemodynamic instability have the worst prognosis. However, what is understood by haemodynamic instability has not been clearly defined.

The Registro Informatizado de la Enfermedad Tromboembólica (RIETE) is an ongoing registry of consecutive patients with symptomatic, objectively confirmed, acute deep vein thrombosis or PE. The present authors compared the predictive value of a systolic blood pressure (SBP) value of <100 mmHg and <90 mmHg and the shock index (cardiac frequency divided by SBP) on 30-day mortality in consecutive patients with PE.

As of May 2006, 6,599 patients with PE were enrolled in the study. Of these, 417 (6.3%) died within 30 days: 153 of the initial PE, 29 of recurrent PE and 235 due to other causes. Of the 417 individuals who died, 127 (30%) had a positive shock index, 60 (14%) had SBP <100 mmHg and 33 (7.9%) had SBP <90 mmHg. On multivariate analysis any of the three parameters were independently associated with an increased mortality. The shock index had a higher sensitivity (30.5 versus 14.4 and 7.9% for SBP <100 mmHg and <90 mmHg, respectively) but lower specificity (86.3 versus 93.0 and 96.6).

All three measures of haemodynamic instability are independent predictors of 30-day mortality. However, while the shock index had the highest sensitivity, a systolic blood pressure value <90 mmHg had the highest specificity.

  • Haemodynamic instability
  • hypotension
  • prognosis
  • pulmonary embolism
  • shock index
  • survival

The Seventh American College of Chest Physicians consensus guidelines 1 recommend initial therapy with heparin for patients with acute nonmassive pulmonary embolism (PE), and suggest the use of thrombolytic therapy for those who are haemodynamically unstable. The British Thoracic Society (BTS) guidelines for the management of acute PE 2 recommend outpatient treatment for patients who are clinically stable. The most important criterion to characterise acute PE as massive is systemic arterial hypotension 3; however, this term is not clearly defined in the literature. Indeed, definitions for haemodynamic instability or massive PE varied among the studies: some used the criterion of a systolic blood pressure (SBP) value <90 mmHg 4, 5; others used SBP <100 mmHg 6–10; and others used the shock index (cardiac frequency divided by SBP) 11. In some studies no definition was provided.

The Registro Informatizado de la Enfermedad Tromboembólica (RIETE) initiative is an ongoing, international (Spain, France, Italy, Israel and Argentina), multicentre, prospective registry of consecutive patients presenting with symptomatic acute venous thromboembolism (VTE) confirmed by objective tests 12–16. The aim of the present study was to compare the predictive value of the three clinical parameters (shock index, SBP <100 mmHg and SBP <90 mmHg) on 30-day mortality in all patients with acute PE.

PATIENTS AND METHODS

Patient entry criteria

Participating hospitals in the RIETE Registry (see Acknowledgements) prospectively enrol consecutive patients with symptomatic, acute deep vein thrombosis (DVT) or PE, confirmed by objective tests, as previously reported. All patients provided oral consent to participate in the Registry, according to the requirements of the ethics committee within each hospital.

Study end-points

The primary end-point was defined as a 1-month mortality. SBP and cardiac frequency were measured at presentation to the emergency department, and the shock index (cardiac frequency divided by SBP) was calculated in all PE patients for further stratification. A positive shock index was defined as ≥1 (haemodinamically unstable patients) and a negative shock index as <1 (haemodinamically stable patients).

Study variables and definitions

The following parameters were recorded: baseline characteristics; clinical status, including any coexisting or underlying conditions, such as chronic heart or lung disease; risk factors for PE; type and dose of treatment received upon PE diagnosis; and outcome during the first 30 days of therapy. Immobilised patients are defined in the present analysis as nonsurgical patients who had been immobilised (i.e. total bed rest with bathroom privileges) for ≥4 days in the 2-month period prior to PE diagnosis. Surgical patients are defined as those who had undergone an operation in the 2 months prior to VTE diagnosis. Creatinine clearance was estimated with the formula by Cockcroft and Gault 17. The first creatinine measured after PE diagnosis was used to calculate creatinine clearance. The causes of death were determined by the attending physicians. In case of doubt, the case report was addressed to the Adjudication Committee of the RIETE Registry.

Statistical analysis

A p-value <0.05 was considered to be statistically significant. First, the influence of a number of variables on the risk of 1-week and 30-day mortality was tested by bivariate analysis with Chi-squared test. Candidate variables were based on published literature. Multivariate analysis was carried out using a logistic regression analysis in the former case and a Cox proportional hazard analysis in the latter, in order to identify predictors of mortality and the independence of the three variables. Then, a receiver operating characteristic (ROC) curve analysis was performed 18. Finally, the sensitivity, specificity, and positive and negative predictive values were compared in order to assess the accuracy of the three variables to predict mortality.

RESULTS

As of May 2006, 6,599 consecutive patients with acute, symptomatic PE had enrolled in RIETE: 3,042 males and 3,557 females, aged 14–99 yrs (mean 68 yrs). PE diagnosis was confirmed in 4,138 patients with a positive computed tomography scan, 2,801 with a high-probability ventilation–perfusion lung scan, 69 with a positive angiogram, 36 with visualisation of a thrombus on the echocardiogram and 124 patients with intermediate-probability lung scan plus evidence of DVT in the lower limbs.

A total of 417 (6.3%) patients died during the first 30 days. The causes of death were: the initial PE event in 153 (37%) patients; recurrent PE in 29 (7.0%); and other causes in 235 (56%) patients. Of the 417 patients who died, 127 (30%) had a positive shock index, 60 (14%) had SBP <100 mmHg and 33 (7.9%) had SBP <90 mmHg.

The patients who died were significantly older, more often in-patients and weighed less than those who survived (table 1⇓). More often they also had cancer, immobility for ≥4 days, renal insufficiency, chronic heart failure or recent major bleeding, but less often, a prior episode of VTE or recent surgery. As for their clinical presentation, patients who died were more often those who had tachycardia, hypotension, atrial fibrillation or hypoxaemia at presentation. On multivariate analysis, the hazard ratios (95% confidence interval (CI)) for 1-month mortality were 2.3 (1.5–3.6) for positive shock index, 1.6 (1.0–2.5) for SBP <100 mmHg and 1.7 (0.9–3.2) for SBP <90 mmHg, as shown in table 2⇓ and in figures 1⇓–⇓3⇓.

Fig. 1—
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig. 1—

Kaplan–Meier survival curves using the Cox model for patients with (·······: shock index ≥1.0) and without (——: shock index <1.0) positive shock index.

Fig. 2—
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig. 2—

Kaplan–Meier survival curves using the Cox model for patients with (·······) and without (——) systolic blood pressure <100 mmHg.

Fig. 3—
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig. 3—

Kaplan–Meier survival curves using the Cox model for patients with (·······) and without (——) systolic blood pressure <90 mmHg.

View this table:
  • View inline
  • View popup
Table 1—

Clinical characteristics and treatment details of 6,599 patients with acute pulmonary embolism according to 30-day mortality

View this table:
  • View inline
  • View popup
Table 2—

Multivariate analysis(Cox proportional hazard models) on the risk of death at 30 days

The shock index had a higher sensitivity than either SBP <100 mmHg or SBP <90 mmHg but a lower specificity, as shown in table 3⇓. There were no significant differences in sensitivity, specificity and positive or negative predictive value, whether the cause of death was the initial PE event, recurrent PE or other reasons (table 3⇓). The area under the ROC curve (95% CI) was 0.79 (0.77–0.82) for the positive shock index, 0.78 (0.75–0.80) for SBP <100 mmHg and 0.77 (0.75–0.80) for SBP <90 mmHg.

View this table:
  • View inline
  • View popup
Table 3—

Predictive value of the three variables in the prediction of 30-day mortality

DISCUSSION

The present data, obtained from a large prospective series of consecutive patients in the RIETE Registry, confirm that any of the three mentioned parameters (shock index, SBP <100 mmHg and SBP <90 mmHg) are independent predictors of 30-day mortality in patients with acute PE. The observation that haemodynamic instability at presentation predicts an adverse outcome in acute PE is certainly not new but confirms previous data from recent decades 3–11. In the present authors’ experience, the three shock parameters examined are equally good (or equally inadequate) in predicting an adverse outcome, since they all appear significant in the Cox model but do not possess high sensitivity or specificity. However, some differences were found among them in terms of sensitivity and specificity that may be relevant in clinical practice.

Two of the most controversial and unsolved issues in the treatment of acute PE are the selection of patients for outpatient therapy and the role of thrombolysis. There is growing evidence that outpatient therapy with low-molecular weight heparin is effective and safe for most patients with PE 19, 20. Based on this evidence, the BTS guidelines for the management of acute PE 2 recommend outpatient treatment for clinically stable patients. However, this was not defined. Of the 417 patients who died in the current series, 30% had a positive shock index and 7.9% had SBP <90 mmHg. This higher sensitivity of the shock index makes it more useful when trying to identify a subgroup of patients at low risk of death. Of course, the shock index alone is not sensitive or specific enough to decide which candidates should receive home therapy but, combined with other independent variables (i.e. age, body weight, immobility, cancer, hypoxaemia or renal insufficiency), it should be preferred over SBP alone.

In the other extreme, the benefit of thrombolysis or other aggressive therapies over heparin appears only in PE patients at high risk for death 21–27. However, since thrombolytic therapy doubles the risk for major bleeding 21, careful and rapid risk assessment is paramount in selecting the appropriate treatment strategy in these patients. In the current study, only 3.4% of those who survived had SBP <90 mmHg, while 14% had a positive shock index. In the present authors’ opinion, this higher specificity of SBP <90 mmHg would better help identify the subgroup of patients at high risk for death.

The present study has some limitations. First, the 6.3% death rate in the current series is slightly lower than the 5.0–15% rates observed in other studies 6, 7, 11, 28, 29. These differences may be attributed to either different observation periods (30 days in the present study) or the need for objective confirmation of PE diagnosis in RIETE. Some patients with severe PE may have died before getting an objective confirmation or were not enrolled as they could not give informed consent. Secondly, the shock index, as a ratio, is subject to many problems (e.g. inappropriate relative bradycardia with a low SBP can still give a patient a positive shock index, clearly undesirable). Thirdly, although the shock index had a higher sensitivity than either of the SBP parameters, it remains quite low (30.5%), and the positive predictive values are very low and very close. Thus, a negative shock index does not guarantee an uncomplicated hospital course since the overall mortality rate at 30 days in these patients was 5.2% (95% CI 4.6–5.8). Physicians should also consider the utility of other methods to detect patients at high risk of dying (i.e. echocardiography, cardiac biomarkers). Finally, as an observational study, RIETE is not designed to answer questions regarding the relative efficacy and safety of different modalities of therapy. Data from the Registry are hypothesis generating and provide feedback from real-world clinical situations which may be of value when designing new randomised clinical studies.

In summary, all three measures of haemodynamic instability are independent predictors of 30-day mortality. This issue is important since these criteria are used when deciding whether a patient with acute pulmonary embolism should be hospitalised or receive thrombolytic therapy. Given their low positive predictive value, they are not particularly predictive of a poor outcome but their absence is highly predictive of a good outcome (given their high negative predictive value). Interestingly, this was true whether the patients died of pulmonary embolism or another cause. Although a shock index of >1 was more sensitive and an systolic blood pressure <90 mmHg more specific, these statistically significant differences were not very important in clinical meaningful terms.

Acknowledgments

The members of the RIETE group are as follows.

Spain. Albacete: J.L. Beato (Hospital de Hellín); Alicante: L. Hernández (Hospital General Universitario de Alicante), A. Maestre (Hospital General Universitario de Elche, Elche); Asturias: I. López (Hospital San Agustín, Avilés); Barcelona: C. Falgá (Consorci Hospitalari de Mataró), M. Monreal (Hospital Universitari Germans Trias i Pujol, Badalona), E. Raguer (Hospital de Terrassa), A. Raventos (Hospital Municipal de Badalona), C. Tolosa (Corporació Sanitària Parc Taulí, Sabadell), M. Valdés (Hospital de Viladecans); Cáceres: J.M. Calvo (Hospital Ciudad de Coria), J.F. Sánchez (Hospital San Pedro de Alcántara); Ciudad Real: J. Portillo (Complejo Hospitalario de Ciudad Real); Córdoba: A. Blanco (Hospital Universitario Reina Sofía), L. López (Hospital Provincial Reina Sofía); Cuenca: J.A. Nieto (Hospital General Virgen de la Luz, Cuenca); Gerona: F. García-Bragado (Hospital Universitari Dr Josep Trueta), S. Soler (Hospital Sant Jaume, Olot); Granada: J.I. Arcelus, I. Casado (Hospital Universitario Virgen de las Nieves); Logroño: M. Barrón (Complejo Hospitalario San Millán y San Pedro); Madrid: R. Barba (Fundación Hospital Alcorcón), C. Fernández-Capitán (Hospital Universitario La Paz), J. Gutiérrez (Hospital Monográfico Asepeyo, Coslada), D. Jiménez (Hospital Ramón y Cajal), O. Madridano (Hospital Universitario La Paz), N. Ruiz-Giménez (Hospital Universitario de la Princesa); Lugo: R. Rabuñal (Complexo Hospitalario Xeral-Calde); Málaga: R. Guijarro, J.J. Martín (Hospital General Universitario Carlos Haya), M. Guil (Hospital Comarcal de la Axarquía, Vélez-Málaga); Murcia: J. Trujillo (Hospital General Santa María del Rosell, Cartagena); Pamplona: R. Lecumberri (Clínica Universitaria de Navarra), M.T. Orue (Hospital de Navarra), G. Tiberio (Hospital Virgen del Camino); Pontevedra: J. Montes (Hospital de Meixoeiro, Vigo), M.J. Núñez (Hospital Comarcal do Salnés, Vilagarcía de Arousa); Santander: R. Valle (Hospital Sierrallana, Torrelavega); Sevilla: R. Otero (Hospital Virgen del Rocío); Tarragona: L. Font (Hospital de Tortosa Vergel de la Cinta, Tortosa); Teruel: J. Vela (Hospital de Alcañiz); Valencia: F. López (Hospital Arnau de Vilanova, Arnau de Vilanova), M.D. Naufall, J.A. Todolí (Hospital Universitario La Fe), P. Román (Hospital General de Requena); Vizcaya: F. Uresandi (Hospital de Cruces); Zaragoza: F. Conget (Hospital Clínico).

France. Saint-Etienne: P. Mismetti, K. Rivron-Guillot (Hospital Bellevue).

Italy. Genoa: R. Poggio (Ospedale Galliera); Naples: P. Di Micco, M.T. Iannuzo (Ospedale Buonconsiglio Fatebenefratelli); Padua: P. Prandoni (Clinica Medical Il University of Padua); Parma: R. Quintavalla (Azienda Ospedaliera Universitaria); Rimini: E. Tiraferri (Ospedale Infermi).

The authors would like to thank S. Ortiz (Universidad Autónoma de Madrid and S&H Medical Science Service; both Madrid, Spain) for statistical analysis of the data and the Registry Coordinating Centre (S&H Medical Science Service) for logistic and administrative support.

  • Received June 14, 2007.
  • Accepted August 22, 2007.
  • © ERS Journals Ltd

References

  1. ↵
    Büller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126: Suppl. 3 401S–428S.
    OpenUrlCrossRefPubMedWeb of Science
  2. ↵
    British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470–483.
    OpenUrlFREE Full Text
  3. ↵
    Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation 2006;113:577–582.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation 2005;112:e28–e32.
    OpenUrlFREE Full Text
  5. ↵
    Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mmHg or higher. Arch Intern Med 2005;165:1777–1781.
    OpenUrlCrossRefPubMedWeb of Science
  6. ↵
    Wicki J, Perrier A, Perneger TV, Bounameaux H, Junod AF. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost 2000;84:548–552.
    OpenUrlPubMedWeb of Science
  7. ↵
    Nendaz MR, Bandelier P, Aujesky D, et al. Validation of a risk score identifying patients with acute pulmonary embolism, who are at low risk of clinical adverse outcome. Thromb Haemost 2004;91:1232–1236.
    OpenUrlPubMedWeb of Science
  8. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172:1041–1046.
    OpenUrlCrossRefPubMedWeb of Science
  9. Aujesky D, Roy PM, Le Manach CP, et al. Validation of a model to predict adverse outcomes in patients with pulmonary embolism. Eur Heart J 2006;27:476–481.
    OpenUrlAbstract/FREE Full Text
  10. ↵
    Aujesky D, Obrosky DS, Stone RA, et al. A prediction rule to identify low-risk patients with pulmonary embolism. Arch Intern Med 2006;166:169–175.
    OpenUrlCrossRefPubMedWeb of Science
  11. ↵
    Kucher N, Luder CM, Dörnhöfer T, Windecker S, Meier B, Hess OM. Novel management strategy for patients with suspected pulmonary embolism. Eur Heart J 2003;24:366–376.
    OpenUrlAbstract/FREE Full Text
  12. ↵
    Arcelus JI, Caprini JA, Monreal M, Suárez C, González-Fajardo JA. The management and outcome of acute venous thromboembolism: a prospective registry including 4011 patients. J Vasc Surg 2003;38:916–922.
    OpenUrlCrossRefPubMedWeb of Science
  13. Trujillo-Santos J, Perea-Milla E, Jiménez-Puente A, et al. Bed rest or ambulation in the initial treatment of patients with acute deep vein thrombosis or pulmonary embolism: findings from the RIETE registry. Chest 2005;127:1631–1636.
    OpenUrlCrossRefPubMedWeb of Science
  14. Barba R, Marco J, Martín-Alvarez H, et al. The influence of extreme body weight on clinical outcome of patients with venous thromboembolism: findings from a prospective registry (RIETE). J Thromb Haemost 2005;3:856–862.
    OpenUrlCrossRefPubMedWeb of Science
  15. Monreal M, Falgá C, Valle R, et al. Venous thromboembolism in patients with renal insufficiency: findings from the RIETE Registry. Am J Med 2006;119:1073–1079.
    OpenUrlCrossRefPubMedWeb of Science
  16. ↵
    Trujillo-Santos J, Herrera S, Page MA, et al. Predicting adverse outcome in outpatients with acute deep vein thrombosis: findings from the RIETE Registry. J Vasc Surg 2006;44:789–793.
    OpenUrlCrossRefPubMedWeb of Science
  17. ↵
    Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31–41.
    OpenUrlCrossRefPubMedWeb of Science
  18. ↵
    Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982;143:29–36.
    OpenUrlPubMedWeb of Science
  19. ↵
    Wells PS, Kovacs MJ, Bormanis J, et al. Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin: a comparison of patient self-injection with homecare injection. Arch Intern Med 1998;158:1809–1812.
    OpenUrlCrossRefPubMedWeb of Science
  20. ↵
    Wells PS, Anderson DR, Rodger MA, et al. A randomized trial comparing 2 low-molecular-weight heparins for the outpatient treatment of deep vein thrombosis and pulmonary embolism. Arch Intern Med 2005;165:733–738.
    OpenUrlCrossRefPubMedWeb of Science
  21. ↵
    Wan S, Quinlan DJ, Agnelli G, Eikelboom JW. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation 2004;110:744–749.
    OpenUrlAbstract/FREE Full Text
  22. Agnelli G, Becattini C, Kirschtein T. Thrombolysis versus heparin in the treatment of pulmonary embolism: a clinical outcome-based meta-analysis. Arch Intern Med 2002;162:2537–2541.
    OpenUrlCrossRefPubMedWeb of Science
  23. Dalen JE. The uncertain role of thrombolytic therapy in the treatment of pulmonary embolism. Arch Intern Med 2002;162:2521–2523.
    OpenUrlCrossRefPubMedWeb of Science
  24. Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part II. Risk stratification, treatment, and prevention. Circulation 2003;108:2834–2838.
    OpenUrlFREE Full Text
  25. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Management Strategies and Prognosis of Pulmonary Embolism-3 Trial Investigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002;347:1143–1150.
    OpenUrlCrossRefPubMedWeb of Science
  26. Buller HR, Sohne M, Middeldorp S. Treatment of venous thromboembolism. J Thromb Haemost 2005;3:1554–1560.
    OpenUrlCrossRefPubMedWeb of Science
  27. ↵
    Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation 2004;110:3276–3280.
    OpenUrlAbstract/FREE Full Text
  28. ↵
    Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353:1386–1389.
    OpenUrlCrossRefPubMedWeb of Science
  29. ↵
    Konstantinides S, Geibel A, Olschewski M, et al. Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: results of a multicenter registry. Circulation 1997;96:882–888.
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top
View this article with LENS
Vol 30 Issue 6 Table of Contents
European Respiratory Journal: 30 (6)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?
R. Otero, J. Trujillo-Santos, A. Cayuela, C. Rodríguez, M. Barron, J. J. Martín, M. Monreal
European Respiratory Journal Dec 2007, 30 (6) 1111-1116; DOI: 10.1183/09031936.00071007

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?
R. Otero, J. Trujillo-Santos, A. Cayuela, C. Rodríguez, M. Barron, J. J. Martín, M. Monreal
European Respiratory Journal Dec 2007, 30 (6) 1111-1116; DOI: 10.1183/09031936.00071007
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • PATIENTS AND METHODS
    • RESULTS
    • DISCUSSION
    • Acknowledgments
    • References
  • Figures & Data
  • Info & Metrics
  • PDF
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism
  • Diagnosis of pulmonary embolism in hospitalised patients: retrospective survey of an institutional standard
Show more Original Articles: Pulmonary embolism

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society