Usefulness of Bedside Testing for Brain Natriuretic Peptide to Identify Right Ventricular Dysfunction and Outcome in Normotensive Patients With Acute Pulmonary Embolism

doi:10.1016/j.amjcard.2005.11.075

The American Journal of Cardiology

Volume 97, Issue 9, 1 May 2006, Pages 1386-1390

https://doi.org/10.1016/j.amjcard.2005.11.075 Get rights and content

Echocardiographic right ventricular (RV) dysfunction is a well-established prognostic indicator in patients with acute pulmonary embolism. However, the possibility of implementing a rapid and effective triage with biohumoral markers such as brain natriuretic peptide (BNP) may be of value. Sixty-one patients with a first documented episode of acute pulmonary embolism without shock and previous left ventricular dysfunction were prospectively studied. All patients underwent echocardiography and rapid BNP testing on admission. Patients were followed up for in-hospital death, progression to shock, and nonfatal pulmonary embolism recurrence. Overall, 35 patients (57%) had echocardiographic evidence of RV dysfunction on admission, and its prevalence increased progressively with increasing levels of BNP. A BNP level <85 pg/ml was highly accurate in excluding RV dysfunction. No patient in the lower tertile of BNP values (1.1 to 85.0 pg/ml) had RV dysfunction, compared with 75% in the middle tertile (88.7 to 487.0 pg/ml) and 100% in the upper tertile (527 to 1,300 pg/ml). Overall, 11 patients (18%), belonging to the upper tertile, progressed to shock during admission, 4 of whom died. The association of RV dysfunction with a BNP level in the upper tertile (≥527 pg/ml) showed incremental prognostic value over RV dysfunction alone (in-hospital death and progression to shock were 55% and 31%, respectively). In the present study, BNP represented a powerful predictor of in-hospital clinical deterioration, with substantial incremental prognostic value over echocardiography alone.

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Cited by (127)

Shock score for prediction of clinical outcomes among stable patients with acute symptomatic pulmonary embolism
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The Composite Pulmonary Embolism Shock (CPES) score has been developed to identify normotensive patients with acute pulmonary embolism (PE) and a low cardiac index (referred to as normotensive shock). We aimed to externally assess the validity of this model for predicting a complicated course among hemodynamically stable patients with acute PE.
Using prospectively collected data from the PROgnosTic valuE of Computed Tomography scan (PROTECT) study, we calculated the CPES score for each patient and the proportion of patients with a score > 3. We calculated the test performance characteristics to predict a complicated course (i.e., death from any cause, hemodynamic collapse, or recurrent PE) and the discriminatory power using the area under the receiver operating characteristic curve.
Sixty-three of the 848 (7.4 %) patients had a complicated course during the 30-day follow-up period. Of the 848 enrolled patients, the CPES score was positive (i.e., score > 3) in 78 (9.2 %). The specificity was 92.1 % (723/785), the positive predictive value was 20.5 % (16/78), and the positive likelihood ratio was 3.22 for a complicated course. The areas under the receiver operating characteristic curve for a complicated course were 0.71 (95 % confidence interval [CI], 0.65–0.78). With the higher score risk classification threshold (cutoff score > 4), the proportion of patients designated as positive was 2.1 %, and the specificity was 98.1 %. When echocardiographic right ventricle (RV) dysfunction was replaced by computed tomographic RV enlargement, the specificity was 85.4 %, the positive predictive value was 14.2 %, and the positive likelihood ratio was 2.06 for a complicated course. When analyses were restricted to the subgroup of patients with intermediate-risk PE, the specificity and the positive predictive value for a complicated course were identical to the overall cohort.
The CPES score has acceptable C-statistic, excellent specificity, and low positive predictive value for identification of hemodynamic deterioration in normotensive patients with PE.
ClinicalTrials.gov number: NCT02238639.
Aggressive Treatment of Intermediate-Risk Patients with Acute Symptomatic Pulmonary Embolism
2018, Clinics in Chest Medicine
Assessment of coexisting deep vein thrombosis for risk stratification of acute pulmonary embolism
2018, Thrombosis Research
Citation Excerpt :
The central coordinating center prospectively determined the simplified Pulmonary Embolism Severity Index (sPESI), as previously described [5]. The study defined echocardiographic right ventricular (RV) dysfunction as the presence of at least two of the following: dilatation of the RV (end-diastolic diameter >30 mm from the parasternal view or the RV appearing larger than the left ventricle from the subcostal or apical view), hypokinesis of the RV free wall (any view), and estimated systolic pulmonary artery pressure over 30 mm Hg [10]. PROTECT defined cTnI concentrations of >0.05 ng/mL as indicative of myocardial injury (cTnI positive) [11].
In patients with acute pulmonary embolism (PE), studies have shown an association between coexisting deep vein thrombosis (DVT) and short-term prognosis. It is not known whether complete compression ultrasound testing (CCUS) improves the risk stratification of their disease beyond the recommended prognostic models.
We included patients with normotensive acute symptomatic PE and prognosticated them with the European Society of Cardiology (ESC) risk model for PE. Subsequently, we determined the prognostic significance of coexisting DVT in patients with various ESC risk categories. The primary endpoint was a complicated course after the diagnosis of PE, defined as death from any cause, haemodynamic collapse, or adjudicated recurrent PE.
According to the ESC model, 37% of patients were low-risk, 56% were intermediate-low risk, and 6.7% were intermediate-high risk. CCUS demonstrated coexisting DVT in 375 (44%) patients. Among the 313 patients with low-risk PE, coexisting DVT (46%) did not show a significant increased risk of complicated course (2.8%; 95% confidence interval [CI], 0.8%–7.0%), compared with those without DVT (0.6%; 95% CI, 0%–3.2%), (P = 0.18). Of the 478 patients with intermediate-low risk PE, a complicated course was 14% and 6.8% for those with and without DVT, respectively (P = 0.01). Of the 57 patients that had intermediate-high risk PE, a complicated course occurred in 17% and 18% for those with and without DVT, respectively (P = 1.0).
In normotensive patients with PE, testing for coexisting DVT might improve risk stratification of patients at intermediate-low risk for short-term complications.
New Concepts in the Management of Pulmonary Embolus
2018, Atlas of Endovascular Venous Surgery, Second Edition
Acute pulmonary embolism (PE) continues to be a major cause of morbidity and mortality worldwide. Overall, the strongest prognostic factor of short-term mortality is hemodynamic status at time of presentation. There are three types of acute PEs defined in the literature: massive, submassive, and nonmassive PE. Massive PE is defined as an acute PE with evidence of hemodynamic instability or systolic blood pressure < 90 mm Hg. Conventionally, patients with acute, symptomatic PE who present with shock or arterial hypotension warrant thrombolysis. However, in PE patients with preserved hemodynamic function, patient risk stratification is paramount in dictating therapeutic options. In patients with high-risk PE, primary reperfusion treatment, particularly systemic fibrinolysis, is the treatment of choice. This method can rapidly reduce thrombus burden, RV dysfunction, and pulmonary vascular resistance. Percutaneous catheter-directed therapy (CDT) has emerged as a viable option for patients with submassive or massive PE who have contraindications to thrombolysis and for whom thrombolysis has not improved hemodynamic compromise. Other clot removal devices are discussed.
Different time course of plasma lactate, troponin I and Nt-proBNP concentrations in patients with acute pulmonary embolism
2017, Thrombosis Research
The prognostic importance of thiol/disulfide homeostasis in patients with acute pulmonary thromboembolism
2016, American Journal of Emergency Medicine
The aim of this study was to evaluate the role of thiol/disulfide homeostasis in acute pulmonary embolism (APE) and investigate its compliance to show hospital mortality of patients with APE.
A total of 173 participants including 113 patients with APE, and 60 healthy individuals were included in the study. APE group was categorized into two subgroups according to Pulmonary Embolism Severity Index (PESI) clinic risk score (PESI low group [n = 71, class 1-3] and PESI high group [n = 42, class 4-5]).
Mean level of native thiol was lower and disulfide level and disulfide/total thiol ratio were higher in APE group than control group. In APE group, 14 patients died during hospitalization. Native thiol and disulfide level, presence of shock, heart rate, oxygen saturation, right ventricular dysfunction, N-terminal pro–brain natriuretic peptide, and creatinine levels were found to have prognostic significance in univariate analysis. On multilvariable logistic regression analysis, native thiol and disulfide level (odds ratio [OR], 1.16(0.87-1.36); P = .010 and OR, 1.49; P = .015, respectively), presence of shock (OR, 1.04; P = .012) and N-terminal pro–brain natriuretic peptide (OR, 1.67; P = .002) were strong predictors for APE-related hospital mortality after the adjustment of other potential confounders.
We have shown that thiol/disulfide homeostasis can be altered during APE and associated with worse hemodynamic parameters, and may be used as a prognostic marker for hospital mortality.

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MiscellaneousUsefulness of Bedside Testing for Brain Natriuretic Peptide to Identify Right Ventricular Dysfunction and Outcome in Normotensive Patients With Acute Pulmonary Embolism

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am Heart J

Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure

N Eng J Med

Miscellaneous
Usefulness of Bedside Testing for Brain Natriuretic Peptide to Identify Right Ventricular Dysfunction and Outcome in Normotensive Patients With Acute Pulmonary Embolism