Skip to main content
SpringerLink
Log in

Prognostic significance of multidetector computed tomography in normotensive patients with pulmonary embolism: rationale, methodology and reproducibility for the PROTECT study

  • Published:
Journal of Thrombosis and Thrombolysis Aims and scope Submit manuscript

Abstract

The PROTECT study is designed to assess the prognostic significance of multidetector computed tomography (MDCT) findings in normotensive outpatients with pulmonary embolism (PE). MDCT assesses right ventricular dysfunction (RVD) by measuring the ratio of the right-to-left ventricular short axis diameters. The study uses 30-day all-cause mortality as the primary outcome. The study determined inter- and intraobserver reproducibility of CT findings of RVD. According to the local radiologists’ measurements, 44 % of patients (42/96) showed RVD (defined as a ratio of the RV to the LV short axis greater than 0.9). The intraclass correlation was good (0.773, CI 95 %, 0.678–0.842). For interobserver reproducibility, the weighted kappa measurement was 0.730. Intraobserver reproducibility was very good (0.932, 95 % CI, 0.880–0.962). The PROTECT study is designed to show the prognostic significance of MDCT for PE. Inter- and intraobserver agreement of interpretation of RVD were good.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Goldhaber SZ, De Rosa M (1999) Acute pulmonary embolism: clinical outcomes in the international cooperative pulmonary embolism registry. Lancet 353:24–27

    Article  Google Scholar 

  2. Douketis JD, Bates S, Duku EK, Ginsberg JS (1998) Risk of fatal pulmonary embolism in patients with treated venous thromboembolism. J Am Med Assoc 279:458–462

    Article  CAS  Google Scholar 

  3. Buller HR, Decousus H, Gallus A, Gent M, Piovella F, Prins MH, Raskob G, van den Berg-Segers AE, Cariou R, et al.; Matisse Investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med 2003; 349: 1695–1702

    Google Scholar 

  4. Jimenez D, Yusen RD, Otero R et al (2007) Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. Chest 132:24–30

    Article  PubMed  Google Scholar 

  5. Aujesky D, Perrier A, Roy PM et al (2007) Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med 261:597–604

    Article  PubMed  CAS  Google Scholar 

  6. Jaff MR, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins S, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK (2011) On behalf of the American Heart, Association Council on Cardiopulmonary CC, Perioperative and Resuscitation, Council on Peripheral Vascular Disease, and Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830

    Article  PubMed  Google Scholar 

  7. Jimenez D, Yusen RD (2010) Risk stratification of normotensive patients with acute symptomatic pulmonary embolism. Br J Haematol 151:415–424

    Article  PubMed  Google Scholar 

  8. Jiménez D, Moores L, Gómez V, Lobo JL, Uresandi F, Otero R, Monreal M, Muriel A, Yusen RD; RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170:1383–1389

    Google Scholar 

  9. Goldhaber SZ (2002) Echocardiography in the management of pulmonary embolism. Ann Intern Med 136:691–700

    PubMed  Google Scholar 

  10. Lang RM, Bierig M, Devereux RB et al (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18:1440–1463

    Article  PubMed  Google Scholar 

  11. Dell’Italia LJ (1991) The right ventricle: anatomy, physiology, and clinical importance. Curr Probl Cardiol 16:653–720

    PubMed  Google Scholar 

  12. Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP, Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL, Zamorano JL, Andreotti F, Ascherman M, Athanassopoulos G, De Sutter J, Fitzmaurice D, Forster T, Heras M, Jondeau G, Kjeldsen K, Knuuti J, Lang I, Lenzen M, Lopez-Sendon J, Nihoyannopoulos P, Perez Isla L, Schwehr U, Torraca L, Vachiery JL (2008) Task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 29:2276–2315

    Article  PubMed  CAS  Google Scholar 

  13. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV Jr, Popovich J Jr, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK; PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317–2327

    Google Scholar 

  14. Perrier A, Roy PM, Sanchez O, Le Gal G, Meyer G, Gourdier AL, Furber A, Revel MP, Howarth N, Davido A, Bounameaux H (2005) Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med 352:1760–1768

    Article  PubMed  CAS  Google Scholar 

  15. van Belle A, Buller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, Kramer MH, Kruip MJ, Kwakkel-van Erp JM, Leebeek FW, Nijkeuter M, Prins MH, Sohne M, Tick LW; Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006; 295: 172–179

    Google Scholar 

  16. Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ (2004) Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation 110:3276–3280

    Article  PubMed  Google Scholar 

  17. Araoz PA, Gotway MB, Harrington JR, Harmsen WS, Mandrekar JN (2007) Pulmonary embolism: prognostic CT findings. Radiology 242:889–897

    Article  PubMed  Google Scholar 

  18. van der Meer RW, Pattynama PM, van Strijen MJ, van den Berg-Huijsmans AA, Hartmann IJ, Putter H, de Roos A, Huisman MV (2005) Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology 235:798–803

    Article  PubMed  Google Scholar 

  19. Quiroz R, Kucher N, Schoepf J, Quiroz R, Costello P, Goldhaber SZ (2004) Right ventricular enlargement on chest computed tomography. Prognostic role in acute pulmonary embolism. Circulation 109:2401–2404

    Article  PubMed  Google Scholar 

  20. Remy-Jardin M, Remy J, Wattinne L, Giraud F (1992) Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breath-hold-technique-comparison with pulmonary angiography. Radiology 185:381–387

    PubMed  CAS  Google Scholar 

  21. Stein PD, Beemath A, Matta F, Goodman LR, Weg JG, Hales CA, Hull RD, Leeper KV, Sostman D, Woodward PK (2008) Enlarged right ventricle without shock in acute pulmonary embolism: prognosis. Am J Med 121:34–42

    Article  PubMed  Google Scholar 

  22. 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 pulmonary embolism, normal blood pressure and echocardiographic right ventricular dysfunction. Circulation 101:2817–2822

    Article  PubMed  CAS  Google Scholar 

  23. Sanchez O, Trinquart L, Caille V, Couturaud F, Pacouret G, Meneveau N, Verschuren F, Roy PM, Parent F, Righini M, Perrier A, Lorut C, Tardy B, Benoit MO, Chatellier G, Meyer G (2010) Prognostic factors for pulmonary embolism: the PREP study, a prospective multicenter cohort study. Am J Respir Crit Care Med 181:168–173

    Article  PubMed  CAS  Google Scholar 

  24. Jiménez D, Díaz G, Molina J, Martí D, Del Rey J, García-Rull S, Escobar C, Vidal R, Sueiro A, Yusen RD (2008) Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. Eur Respir J 31:847–853

    Article  PubMed  Google Scholar 

  25. Pieralli F, Olivotto I, Vanni S, Conti A, Camaiti A, Targioni G, Grifoni S, Berni G (2006) Usefulness of bedside testing for brain natriuretic peptide to identify right ventricular dysfunction and outcome in normotensive patients with acute pulmonary embolism. Am J Cardiol 97:1386–1390

    Article  PubMed  CAS  Google Scholar 

  26. 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 172:1041–1046

    Article  PubMed  Google Scholar 

  27. Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, Gallus AS, Lensing AW, Misselwitz F, Prins MH, Raskob GE, Segers A, Verhamme P, Wells P, Agnelli G, Bounameaux H, Cohen A, Davidson BL, Piovella F, Schellong S (2011) Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 363:2499–2510

    Google Scholar 

  28. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC (2007) STROBE Initiative. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 147:573–577

    Google Scholar 

  29. Harrel FE Jr, Lee KL, Mark DB (1996) Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med 15:361–387

    Article  Google Scholar 

  30. Pencina MJ, D’Agostino RB (2004) Overall C as a measure of discrimination in survival analysis: model specific population value and confidence interval estimation. Stat Med 23:2109–2123

    Article  PubMed  Google Scholar 

  31. Hosmer DW Jr, Lemeshow S (1989) Applied logistic regression. Wiley, New York

    Google Scholar 

  32. Little RJ, Rubin DB (1987) Statistical analysis with missing data. Wiley, New York

    Google Scholar 

  33. Rubin DB, Schenker N (1991) Multiple imputation in health-care databases: an overview and some applications. Stat Med 10:585–598

    Article  PubMed  CAS  Google Scholar 

  34. Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1:307–310

    Article  PubMed  CAS  Google Scholar 

  35. Altman DG (1991) Practical statistics for medical research. Chapman and Hall, London, p 404

    Google Scholar 

  36. Jiménez D, Aujesky D, Moores L, Gómez V, Martí D, Briongos S, Monreal M, Barrios V, Konstantinides S, Yusen RD (2011) Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism. Thorax 66:75–81

    Article  PubMed  Google Scholar 

  37. Kang DK, Thilo C, Schoepf J, Barraza JM, Nance JW, Bastarrika G, Abro JA, Ravenel JG, Costello P, Goldhaber SZ (2011) CT signs of right ventricular dysfunction. Prognostic role in acute pulmonary embolism. J Am Coll Cardiol Img 4:841–849

    Google Scholar 

  38. Becattini C, Agnelli G, Vedovati MC (2011) Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J 32:1657–1663

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Respiratory Department, Ramón y Cajal Hospital, IRYCIS, 28034, Madrid, Spain

    David Jiménez

  2. Respiratory Department, Txagorritxu Hospital, Vitoria, Spain

    José Luis Lobo

  3. Medicine Department, Germans Trias I Pujol Hospital, Badalona, Spain

    Manuel Monreal

  4. Respiratory Department, Virgen del Rocío Hospital, Sevilla, Spain

    Remedios Otero

  5. Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, 63104, USA

    Roger D. Yusen

Authors
  1. David Jiménez
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. José Luis Lobo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Manuel Monreal
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Remedios Otero
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Roger D. Yusen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David Jiménez.

Additional information

This study was conducted on behalf of the PROTECT investigators. The members of the PROTECT investigation are given in the Appendix.

Appendices

Appendix

Coordinator of the PROTECT Study: David Jiménez.

PROTECT Steering Committee Members: David Jiménez, José Luis Lobo, Manuel Monreal, Remedios Otero, Roger D. Yusen.

PROTECT Study Coordinating Center: S & H Medical Science Service.

Data and Safety Monitoring Board: Francisco Conget, Dolores Nauffal, Mikel Oribe, Fernando Uresandi.

Radiological Panel: Ignacio Gallego, Luis Gorospe, Agustina Vicente.

Blood Sample Processing: José Manuel del Rey.

Statiscian: Víctor Abraira, Javier Zamora, Alfonso Muriel.

Investigators of the PROTECT study

Consolación Rodríguez, Jorge Vivancos, Jesús Marín (Bormujos), Mikel Oribe, Aitor Ballaz, Jose María Abaitúa, Sonia Velasco (Galdakao), Manuel Barrón, María Lladó, Carmen Rodrigo, Luis Javier Alonso (Logroño), Ramón Rabuñal, Olalla Castro, Concepción Iglesias, Ana Testa (Lugo), David Jiménez, Vicente Gómez, Luis Gorospe, Sem Briongos, José Manuel del Rey (Madrid), Celso Álvarez, Nuria Rodríguez, Amador Prieto, María Martín (Oviedo), Carmen Navarro, Mónica López, Eva Castañer, Eva Guillaumet (Sabadell), Remedios Otero, Teresa Elías, Pilar Serrano, Francisco López (Sevilla), Reina Valle, María Victoria Piret, Pilar Lucio, José María Cuesta (Sierrallana), Dolores Nauffal, Marta Ballester, José Pamies, Ana Osa (Valencia), José Luis Lobo, Vanesa Zorrilla, Delfina Pozo, Ángel Alonso (Vitoria), Francisco Conget, Miguel Ángel Santolaria, Mariano González, José Luis de Benito (Zaragoza).

Rights and permissions

Reprints and permissions

About this article

Cite this article

Jiménez, D., Lobo, J.L., Monreal, M. et al. Prognostic significance of multidetector computed tomography in normotensive patients with pulmonary embolism: rationale, methodology and reproducibility for the PROTECT study. J Thromb Thrombolysis 34, 187–192 (2012). https://doi.org/10.1007/s11239-012-0709-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11239-012-0709-7

Keywords

Search

Navigation