Figures
- FIGURE 1
Receiver operating characteristics curves for high-sensitivity troponin T (hsTnT) levels on admission with regard to the a) primary (adverse 30-day outcome) and b) secondary (30-day all-cause mortality) outcome in normotensive pulmonary embolism. AUC: area under the curve.
- FIGURE 2
Stepwise approach for risk assessment based on the simplified pulmonary embolism severity index (sPESI), an age-adjusted high-sensitivity troponin T (hsTnT) cut-off value, and echocardiographic evidence of right ventricular (RV) dysfunction. The age-adjusted hsTnT cut-off value was defined as hsTnT levels ≥14 pg·mL−1 in young (age <75 years) patients and hsTnT levels ≥45 pg·mL−1 in elderly (≥75 years) patients.
Tables
- TABLE 1
Baseline characteristics, medical history, and initial presentation of 682 normotensive patients with acute pulmonary embolism
All study patients hsTnT <14 pg·mL−1 hsTnT ≥14 pg·mL−1 p-value Patients n 682 270 412 Male sex 330 (48.4) 132 (48.9) 198 (48.1) 0.832 Age years 70 (54–78) 63 (45–74) 73 (64–80) <0.001 BMI kg·m−2 27.0 (23.9–30.4) 26.4 (23.3–30.1) 27.5 (24.4–30.9) 0.014 Risk factors for VTE and comorbidities Previous VTE 159 (23.3) 75 (27.8) 84 (20.4) 0.027 Recent# immobilisation/trauma/surgery 189 (27.8) (n=681) 54 (20.0) 135 (32.8) (n=411) <0.001 Active cancer§ 115 (16.9) (n=681) 38 (14.1) 77 (18.7) (n=411) 0.112 Chronic heart failure 71 (10.4) (n=681) 15 (5.6) 56 (13.6) (n=411) 0.001 Chronic pulmonary disease 85 (12.5) (n=681) 19 (7.0) 66 (16.1) (n=411) 0.001 Renal insufficiency 207 (30.4) 45 (16.7) 162 (39.3) <0.001 Clinical presentation Symptom duration <24 h 212 (45.6) (n=465) 70 (38.0) (n=184) 142 (50.5) (n=281) 0.008 Chest pain 312 (45.7) 160 (59.3) 152 (36.9) <0.001 Signs of DVT 224 (32.9) (n=681) 88 (32.7) (n=269) 136 (33.0) 0.936 Dyspnoea 558 (81.8) 208 (77.0) 350 (85.0) 0.009 Syncope 119 (17.4) 25 (9.3) 94 (22.8) <0.001 Systolic blood pressure mmHg 130 (115–146) (n=668) 130 (120–150) (n=263) 130 (115–144) (n=405) 0.039 Hypotension+ 50 (7.5) 10 (3.8) 40 (9.9) 0.004 Heart rate beats·min-1 90 (80–107) (n=674) 86 (75–98) (n=265) 95 (83–110) (n=409) <0.001 Tachycardia 247 (36.6) 62 (23.4) 185 (45.2) <0.001 RV dysfunction on echocardiography 219 (37.2) (n=588) 40 (17.7) (n=226) 179 (49.4) (n=362) <0.001 sPESI ≥1 403 (59.1) 101 (37.4) 302 (73.3) <0.001 Data are presented as n (%) or median (interquartile range), unless otherwise stated. Patients were stratified according the high-sensitivity troponin T (hsTnT) cut-off value of 14 pg·mL−1. BMI: body mass index; VTE: venous thromboembolism; DVT: deep vein thrombosis; RV: right ventricular; sPESI: simplified pulmonary embolism severity index. #: within the previous 4 weeks; §: defined as active malignancy, anti-tumour therapy within the last 6 months, or metastatic state; +: defined as systolic blood pressure between 90 and 100 mmHg on admission.
- TABLE 2
Prognostic performance of different high-sensitivity troponin T (hsTnT) cut-off values in all study patients and in elderly (aged ≥75 years) patients with regard to an adverse 30-day outcome
Sensitivity Specificity PPV NPV NRI (95% CI), p-value OR (95% CI), p-value All study patients (n=682) hsTnT ≥14 pg·mL−1 (established) 96 (80–99) 41 (37–45) 6 (4–9) 100 (98–100) 16.64 (2.24–123.74), p=0.006 hsTnT ≥33 pg·mL−1 (patient cohort-specific) 80 (61–91) 64 (60–67) 8 (5–12) 99 (97–100) 0.07 (-0.09–0.23), p=0.385 7.14 (2.64–19.26), p<0.001 Age-adjusted hsTnT cut-off value# 88 (70–96) 54 (50–58) 7 (5–10) 99 (98–100) 0.05 (-0.06–0.17), p=0.369 8.67 (2.57–29.26), p<0.001 Age ≥75 years (n=248) hsTnT ≥14 pg·mL−1 (established) 100 (76–100) 28 (22–34) 7 (4–11) 100 (94–100) ¶ hsTnT ≥45 pg·mL−1 (age-optimised) 83 (55–95) 64 (58–70) 11 (6–19) 99 (95–100) 0.18 (0.01–0.36), p=0.041 9.05 (1.94–42.26), p=0.005 Data are presented as % (95% CI), unless otherwise stated. Abbreviations: PPV: positive predictive value; NPV: negative predictive value; NRI: net reclassification improvement; CI: confidence interval; OR: odds ratio; hsTnT: high-sensitivity troponin T. #: the age-adjusted hsTnT cut-off value was defined as hsTnT levels ≥14 pg mL−1 in young (<75 years) patients and hsTnT levels ≥45 pg mL−1 in elderly (≥75 years) patients. ¶: calculation of the odds ratio was not possible since all patients with hsTnT <14 pg mL−1 had a favourable outcome (sensitivity 100%).
- TABLE 3
Predictors of adverse 30-day outcome in normotensive pulmonary embolism
OR 95% CI p-value C-index Univariable logistic regression analysis Chronic cardiopulmonary disease 3.04 1.33–6.93 0.008 Tachycardia 2.70 1.19–6.10 0.017 Hypotension 3.32 1.19–9.27 0.022 Hypoxia 3.65 1.51–8.81 0.004 RV dysfunction on echocardiography 4.08 1.65–10.07 0.002 sPESI ≥1 8.38 1.96–35.85 0.004 Multivariable logistic regression analysis sPESI ≥1 6.18 1.42–26.92 0.015 0.67 RV dysfunction on echocardiography 3.23 1.29–8.07 0.012 Additional impact hsTnT ≥14 pg·mL−1 7.11 0.91–55.43 0.061 0.76 Age-adjusted hsTnT cut-off value# 4.56 1.30–16.01 0.018 0.77 RV: right ventricular; sPESI: simplified pulmonary embolism severity index; hsTnT: high-sensitivity troponin T. #: age-adjusted hsTnT cut-off value was defined as hsTnT levels ≥14 pg·mL−1 in young (age <75 years) patients and hsTnT levels ≥45 pg·mL−1 in elderly (age ≥75 years) patients.
- TABLE 4
Development of a stepwise approach for risk assessment (primary outcome)
OR 95% CI p-value C-index Sensitivity, % (95% CI) Specificity, % (95% CI) PPV, % (95% CI) NPV, % (95% CI) sPESI ≥1 8.38 1.96–35.85 0.004 0.67 92 (75–98) 42 (38–46) 6 (4–8) 99 (97–100) Additional impact of the age-adjusted hsTnT cut-off value sPESI ≥1 5.85 1.35–25.32 0.018 0.77 80 (61–91) 68 (64–72) 9 (6–13) 98 (97–100) Age-adjusted hsTnT cut-off value# 6.59 1.93–22.44 0.003 Additional impact of RV dysfunction on echocardiography sPESI ≥1 5.07 1.16–22.22 0.031 0.79 61 (41–78) 84 (81–87) 12 (8–20) 98 (97–99) Age-adjusted hsTnT cut-off value# 4.62 1.31–16.29 0.017 RV dysfunction on echocardiography 2.33 0.92–5.96 0.076 Subanalysis of 403 patients with sPESI ≥1 Age-adjusted hsTnT cut-off value# 5.40 1.58–18.47 0.007 0.66 87 (68–96) 45 (40–50) 8 (6–13) 98 (95–99) Additional impact of RV dysfunction on echocardiography Age-adjusted hsTnT cut-off value# 3.70 1.04–13.15 0.043 0.71 67 (45–83) 72 (67–76) 12 (8–20) 97 (95–99) RV dysfunction on echocardiography 2.50 0.93–6.77 0.071 OR: odds ratio; CI: confidence interval; PPV: positive predictive value; NPV: negative predictive value; sPESI: simplified Pulmonary Embolism Severity Index; hsTnT: high-sensitivity troponin T; RV: right ventricular. #: the age-adjusted hsTnT cut-off value was defined as hsTnT levels ≥14 pg·mL−1 in young (age <75 years) patients and hsTnT levels ≥45 pg·mL−1 in elderly (age ≥75 years) patients.
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