Prognostic role of biomarkers and right ventricular dysfunction in pulmonary embolism

Pulmonary embolism is morbidity and mortality remain high. The short-term prognosis of pulmonary embolism depends on haemodynamic status and underlying disease massive pulmonary embolism, defined as pulmonary embolism that is associated with systemic hypotension which increases up to 50% in hospital mortality. However, the in-hospital mortality of patients with normal blood pressure pulmonary embolism has been reported to vary from 3 to 15%. Right ventricular dysfunction showed by echocardiography or computerized tomography and elevated cardiac enzymes have been used to determine mortality in these patients with pulmonary embolism. In this article; we reviewed the prognostic value of right ventricular dysfunction as evaluated by echocardiography or spiral computerized tomography, and the prognostic value of increased levels of cardiac markers in patients with pulmonary embolism.     

Prognostic value of echocardiography and spiral computed tomography in patients with pulmonary embolism

PURPOSE OF REVIEW: The identification of patients with pulmonary embolism who are at risk for mortality or severe morbidity in the early observation period is important because these patients may benefit from more aggressive initial treatment such as thrombolysis or catheter removal of the thrombus. Right ventricular dysfunction has been suggested to have a prognostic value for the occurrence of these adverse outcomes. The purpose of this review is to determine the prevalence and prognostic value of right ventricular dysfunction, in particular in normotensive patients with pulmonary embolism. The association between right ventricular dysfunction and outcome of pulmonary embolism was evaluated for studies using echocardiography, spiral computed tomography, or both to detect right ventricular dysfunction. RECENT FINDINGS: Seven studies using echocardiography with a total of 3468 patients and six studies using spiral computed tomography with a total of 868 patients were identified. The prevalence of right ventricular dysfunction with echocardiography in normotensive patients was approximately 30 to 40%, with a positive predictive value for short-term mortality of approximately 5%. These indices could not be calculated for normotensive patients in the studies that used spiral computed tomography. SUMMARY: The studies using echocardiography show that there is an association between right ventricular dysfunction and prognosis of pulmonary embolism in normotensive patients. Whether this is clinically useful in guiding more aggressive therapy remains to be determined, however. Thus far, the results of the studies with spiral computed tomography are too preliminary to enable definite conclusions to be drawn for the normotensive patient group.     

Clinical course and prognosis of acute pulmonary embolism

Summary Effective treatment of acute pulmonary embolism (PE) requires prompt identification of patients at high risk of death or severe cardiovascular complications during the hospital stay. Determination of prognostic parameters in this heterogeneous patient population is far more important than calculation of a crude mortality rate due to PE. The multicenter Management Strategy and Prognosis in Pulmonary Embolism Registry examined the in-hospital clinical course of 1001 consecutive patients with acute PE. Overall mortality was 22%, with 91% of deaths directly related to PE. Clinical signs of acute right heart failure due to major PE (arterial hypotension, shock, circulatory collapse) were clearly associated with an adverse outcome. Mortality ranged from 8 to 65% depending on the severity of clinical instability at presentation. Importantly, a significantly increased death rate was also observed in patients with echocardiographically detected right ventricular dilation (84 vs. 16%), a reliable noninvasive index of impending right heart failure. The independent prognostic effect of this finding was confirmed by multivariate analysis (Odds Ratio, 2.44; P=0.004). Thus, the combination of clinical and echocardiographic findings permits accurate risk stratification of patients with acute PE. Evidence is also accumulating that these prognostic factors can be used to identify candidates for early thombolytic treatment.     

Biomarkers in pulmonary embolism

PURPOSE OF REVIEW: Controversy exists about the precise role of thrombolytic therapy in normotensive patients with pulmonary embolism. To resolve this controversy two major questions must be addressed. First, can a subgroup of normotensive pulmonary embolism patients with a high risk for adverse outcomes, such as in-hospital mortality or early recurrent venous thromboembolism, be identified? Second, is there convincing evidence that the benefits of more aggressive therapy counterbalance its risks?Troponin I and T as well as brain natriuretic peptide (BNP) have recently been introduced as promising tools in the risk assessment of patients with pulmonary embolism. RECENT FINDINGS: The studies in series of patients with pulmonary embolism showed prevalences of elevated cardiac biomarkers of 16 to 84%. Positive predictive values for in-hospital mortality varied from 6 to 44%, whereas negative predictive values for uneventful outcome were above 93% in all studies. SUMMARY: Although a correlation between elevated biomarkers and in-hospital mortality in pulmonary embolism patients is present in most of the studies, the positive predictive value appears to be insufficient to extend the indication for thrombolytic therapy to all patients with elevated biomarkers. Future research is necessary to show whether combining different biomarkers with echocardiography is more useful.     

Diagnosis and treatment of acute pulmonary embolism in 2010

Diagnostic approaches in acute pulmonary embolism include evaluation of clinical likelihood, D-dimers, echocardiography and spiral CT angiography and pulmonary scintigraphy. Determination of D-dimers is only meaningful in patients with low or intermediate clinical likelihood. It is safe not to initiate anticoagulation treatment (or to discontinue such treatment) in patients with low clinical likelihood of acute pulmonary embolism and negative D-dimer test (only if methods with 99-100% sensitivity are used). Duplex sonography and pulmonary scintigraphy are only necessary at the centres with a first generation spiral CT and not those with multidetector devices. Investigations in normotensive patients should include echocardiography that should also include assessment of the right ventricular function using echocardiography and determination of biomarkers of pulmonary embolism. Right ventricular dysfunction together with elevated troponins identifies a normotensive group at an increases risk. Highly sensitive troponin T (hsTnT) appears to be particularly valuable. Echocardiography reading might the decisive factor for treatment initiation in patients with massive acute pulmonary embolism. Negative or unclear echocardiography finding warrants spiral CT angiography (CTA). Ventilation/perfusion scan or pulmonary arteriography are recommendable in patients with unclear CTA finding and patients with high clinical likelihood of pulmonary embolism and negative CTA finding. A combination of CTA and CTV also appears useful as it increases the overall sensitivity of the investigation and enables imaging of pelvic veins. Thrombolytic treatment is indicated in haemodynamically unstable patients, patients with a high risk of a massive pulmonary embolism associated with cardiogenic shock or hypotension (systolic pressure below 90 mmHg or a decrease in systolic pressure by > 40 mmHg) or symptoms of acute right-sided heart failure. Thrombolytic treatment is also indicated in pulmonary embolism not receding following heparin treatment, in recurring or expanding pulmonary embolism, in the presence of thrombi in the right heart and in patients with right-to-left shunting through patent foramen ovale. This treatment should also be considered in patients with submassive pulmonary embolism associated with a dysfunction of the right ventricle and increased troponins, and particularly in patients lacking even a relative contraindication of thrombolytic treatment. A thrombolytic of choice is alteplase. Embolectomy or catheterization should be used if thrombolytic treatment is contraindicated or ineffective. Long-term monitoring of massive and submassive acute pulmonary embolism is highly recommended. Low molecular weight heparins or unfractioned heparin or fondaparinux are used in haemodynamically stable patients.     

N-terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism.

Plasma brain natriuretic peptide (BNP), released from myocytes of ventricles upon stretch, has been reported to differentiate pulmonary from cardiac dyspnoea. Limited data have shown elevated plasma BNP levels in acute pulmonary embolism (APE), frequently accompanied by dyspnoea and right ventricular (RV) dysfunction. The aim of this study was to assess plasma N-terminal proBNP (NT-proBNP) in APE, and to establish whether it reflects the severity of RV overload and if it can be used to predict adverse clinical outcome. On admission, NT-proBNP and echocardiography for RV overload were performed in 79 APE patients (29 males), aged 63 +/- 16 yrs. Plasma NT-proBNP was elevated in 66 patients (83.5%) and was higher in patients with (median 4,650 pg x mL(-1) (range 61-60,958)) than without RV strain (363 pg x mL(-1) (16-16,329)). RV-to-left ventricular ratio and inferior vena cava dimension correlated with NT-proBNP. All 15 in-hospital deaths and 24 serious adverse events occurred in the group with elevated NT-proBNP, while all 13 (16.5%) patients with normal values had an uncomplicated clinical course. Plasma NT-proBNP predicted in-hospital mortality. Plasma N-terminal pro-brain natriuretic peptide is elevated in the majority of cases of pulmonary embolism resulting in right ventricular overload. Plasma levels reflect the degree of right ventricular overload and may help to predict short-term outcome. Acute pulmonary embolism should be considered in the differential diagnosis of patients with dyspnoea and abnormal levels of brain natriuretic peptide.     

Helical CT pulmonary angiography predictors of in-hospital morbidity and mortality in patients with acute pulmonary embolism

PURPOSE: To determine if CT variables predict in-hospital morbidity and mortality in patients with pulmonary embolism (PE). MATERIALS AND METHODS: CT scans and charts of 173 patients with CT scans positive for PE were reviewed. CT scans were reviewed for leftward ventricular septal bowing, increased right ventricle (RV) to left ventricle (LV) diameter ratio, clot burden, increased pulmonary artery to aorta diameter ratio, and oligemia. Charts were reviewed for severe morbidity and mortality outcomes: death from pulmonary emboli or any cause, and cardiac arrest. Charts were also reviewed for milder morbidity outcomes: intubation, vasopressor use, or admission to an intensive care unit (ICU) and for multiple comorbidities. RESULTS: No CT predictor was significantly associated with severe morbidity or mortality outcomes. Ventricular septal bowing and increased RV/LV diameter ratio were both associated with subsequent admission to an ICU (P = 0.004 and P = 0.025, respectively). Oligemia (either lung) was associated with subsequent intubation; right lung oligemia was associated with the subsequent use of vasopressors. After controlling for history of congestive heart failure, ischemic heart disease, and pulmonary disease, both septal bowing and an increased RV/LV diameter ratio remained associated with admission to an ICU. CONCLUSION: No CT variables predicted severe in-hospital morbidity and mortality (death from pulmonary embolism, death from any cause, or cardiac arrest) in patients with PE. However, ventricular septal bowing and increased RV/LV diameter ratio were both strongly predictive of less severe morbidity, namely, subsequent ICU admission, and oligemia was associated with subsequent intubation and vasopressor use.     

Novel management strategy for patients with suspected pulmonary embolism.

AIMS: A simple management strategy is required for patients with acute pulmonary embolism which allows a rapid and reliable diagnosis in order to start timely and appropriate treatment. METHODS AND RESULTS: Two hundred and four consecutive patients with suspected pulmonary embolism were managed according to a standardized protocol based on the clinical pretest probability and the initial haemodynamic presentation (shock index=heart rate divided by systolic blood pressure). Patients with a high pretest probability and a positive shock index (> or =1) (n=21) underwent urgent transthoracic echocardiography. Based on the presence or absence of right ventricular dysfunction, reperfusion treatment was initiated immediately. Patients with a negative shock index (<1) (n=183) underwent diagnostic evaluation including pretest probability, D-dimer, and spiral computed tomography (CT) as first-line tests. Echocardiography was performed only when a central pulmonary embolism was found in the spiral CT(n=33). According to our strategy, 98 patients met the diagnostic criteria of pulmonary embolism: 75 patients (all shock index <1) were treated with heparin alone, 16 (seven had a shock index > or =1) with thrombolysis, four (all shock index > or =1) with catheter fragmentation, and three (all shock index > or =1) with surgical embolectomy. The all-cause mortality rate at 30 days was 5%, and at 6 months 11%. Right ventricular dysfunction on baseline echocardiography was not associated with a higher mortality rate at 6 months (logrank 2.4, P=0.12). CONCLUSIONS: The novel management strategy for patients with suspected pulmonary embolism resulted in a rapid diagnosis and treatment with a low 30-day mortality. In patients with pulmonary embolism and a positive shock index, time-consuming imaging tests can be avoided to reduce the risk of sudden death and not to delay reperfusion therapy.     

Triaging in pulmonary embolism

Risk stratification of patients with pulmonary embolism represents an important step and may help to guide initial therapeutic management. Pulmonary embolism can be stratified into several groups, with different risk of early death or complications based on the presence of several risk factors. High-risk pulmonary embolism is defined by shock or peripheral signs of hypoperfusion. It is a life-threatening emergency with high short-term mortality (>25%) requiring specific therapeutic strategy with inotropic agents and fibrinolysis. In normotensive patients with pulmonary embolism, the presence of right ventricular dysfunction assessed by echocardiography or myocardial injury based on elevated levels of biomarkers, is associated with an intermediate risk of early death. These patients require close monitoring, and the role of thrombolytic treatment is currently assessed in a large trial. Lastly, patients with normotensive pulmonary embolism and without right ventricular dysfunction or myocardial injury have a low risk of death and complications. These patients may be candidates for home treatment. Several scores combining these risk factors have been described.     

Prognostic Value of Electrocardiography in Elderly Patients with Acute Pulmonary Embolism

BackgroundElectrocardiographic (ECG) signs of right ventricular strain could be used as a simple tool to risk-stratify patients with acute pulmonary embolism.MethodsWe studied consecutive patients aged ≥ 65 years with acute pulmonary embolism in a prospective multicenter cohort study. Two readers independently analyzed 12 predefined ECG signs of right ventricular strain in all patients. The outcome was the occurrence of an adverse clinical event, defined as death from any cause within 90 days or a complicated in-hospital course. We determined the interrater reliability for each ECG sign and examined the association between right ventricular strain signs and adverse events using logistic regression, adjusting for the Pulmonary Embolism Severity Index and cardiac troponin.ResultsOverall, 320/390 patients (82%) showed at least one ECG sign of right ventricular strain. The interrater reliability for individual ECG signs was highly variable (? 0.40-0.95). Patients with ≥ 1 of the 3 classic signs of right ventricular strain (S1Q3T3, right bundle branch block, or T wave inversions in V1-V4) had a higher incidence of adverse events than those without (13% vs 6%; P = .026). After adjustment, the presence of ≥ 1 of the 3 classic signs of right ventricular strain (odds ratio 2.11; 95% confidence interval, 1.00-4.46) and the number of right ventricular strain signs present were significantly associated with adverse events (odds ratio 1.35 per sign; 95% confidence interval, 1.08-1.69).ConclusionsECG signs of right ventricular strain are common in elderly patients with acute pulmonary embolism. Although such signs may have prognostic value, their variable reliability and the rather modest prognostic effect size may limit their usefulness in the risk stratification of pulmonary embolism.     

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

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 microg/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.     

Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism

BACKGROUND: Echocardiographically assessed right ventricular dysfunction is increasingly used to guide more aggressive therapy in hemodynamically stable patients with acute pulmonary embolism (PE). However, the prognostic value of right ventricular dysfunction in these patients is still unclear. METHODS: We systemically reviewed the literature to assess the prevalence of echocardiographic right ventricular dysfunction and the association with adverse outcomes in patients with PE who had this condition. The methodologic quality of each study was scored. Absolute risks of the outcome events were calculated for each study separately, and positive predictive values of PE-related mortality were determined for normotensive patients. RESULTS: Seven studies were included. All had methodologic shortcomings, but they suggested an at least 2-fold increased risk of PE-related mortality in patients with right ventricular dysfunction, the prevalence of which varied from 40% to 70%. However, this seems to be less convincing in hemodynamically stable patients. The only 2 studies that allowed for an estimation of the accuracy in normotensive patients showed low positive predictive values of echocardiographic right ventricular dysfunction for PE-related in-hospital mortality (positive predictive value, 4% and 5% in the 2 studies). CONCLUSION: It remains unclear whether echocardiographic right ventricular dysfunction is a prevalent and reliable predictor of adverse outcomes in hemodynamically stable patients with acute PE.     

Pulmonary embolism incidence is increasing with use of spiral computed tomography

Background

Pulmonary embolism causes significant morbidity in hospitalized patients, yet few studies have explored the impact of spiral computed tomography (CT) scanning on diagnosis and clinical outcome.

Methods

Incidence rates of pulmonary embolism, chest and spiral CT rates, D-dimer assay, anticoagulation, and in-hospital mortality were assessed on statewide pulmonary embolism discharge data (1997-2001) from the Pennsylvania Health Care Cost Containment Council.

Results

The incidence of pulmonary embolism increased from 47 to 63 per 100,000 patients from 1997 to 2001 (mean of 0.004% per year, P < .001). Mean pulmonary embolism incidence rates were higher for African American patients (0.031% per year higher than for white patients), patients aged 70 years or more (0.007% higher than for patients aged < 70 years), and female patients (0.013% higher than for male patients) (all P < .001). Concomitantly, the proportion undergoing CT (including spiral) scans increased from 23.23% to 45.18% (odds ratio = 1.30; P < .001), controlling for age, gender, race, and cancer, whereas rates for other procedures remained unchanged. By comparing 1999 and before with 2000 and after, there was a significant decrease in the 2 highest Atlas Severity of Illness categories (49.4%-37.7%) and a significant increase in the 3 lowest categories (50.6%-62.3%; P < .001). The risk of in-hospital deaths among patients with pulmonary embolism decreased in this period from 12.8% to 11.1% (P < .001).

Conclusion

The incidence of pulmonary embolism is increasing with the increasing use of spiral CT scans, with a lower severity of illness and lower mortality, suggesting the increase is due to earlier diagnosis.     

Derivation and validation of a prognostic model for pulmonary embolism

RATIONALE: An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment. OBJECTIVES: To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes. METHODS: We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our prediction rule using logistic regression with 30-day mortality as the primary outcome, and patient demographic and clinical data routinely available at presentation as potential predictor variables. We externally validated the rule in 221 inpatients with pulmonary embolism from Switzerland and France. MEASUREMENTS: We compared mortality and nonfatal adverse medical outcomes across the derivation and two validation samples. MAIN RESULTS: The prediction rule is based on 11 simple patient characteristics that were independently associated with mortality and stratifies patients with pulmonary embolism into five severity classes, with 30-day mortality rates of 0-1.6% in class I, 1.7-3.5% in class II, 3.2-7.1% in class III, 4.0-11.4% in class IV, and 10.0-24.5% in class V across the derivation and validation samples. Inpatient death and nonfatal complications were 相似文献   

Embolism in the right heart chambers: the diagnostic and therapeutic aspects]

Deep venus thrombosis may result in pulmonary embolism. In rare instances, embolization has occurred, not directly to the pulmonary arterial tree, but to the right heart chambers. Although the value of echocardiography in the diagnosis is well recognised, their is no consensus for the appropriate treatment. We report herein six cases of floating right atrial thrombi, diagnosed by echocardiography, in patients with pulmonary embolism, or unexplained shock or syncope. Surgical embolectomy was carried out in 4 patients, and thrombolytic therapy in 2, without in-hospital mortality. The high mortality associated to this entity may be improved by rapid echocardiographic recognition and emergency treatment with thrombolysis or surgery. Our data suggest the possible use of thrombolysis as a first-choice therapy in selected patients.     

Prognostic significance of troponin elevation and right ventricular enlargement in acute pulmonary embolism

The troponin I values and echocardiographic data of 141 patients with acute pulmonary embolism (PE) were correlated with 30-day mortality. Patients with elevated troponin and right ventricular enlargement are at significantly greater risk for death after PE than patients with only 1 or with neither adverse prognostic marker.     

Prognostic Value of ECG Among Patients with Acute Pulmonary Embolism and Normal Blood Pressure

Objective

To investigate the prognostic value of electrocardiography (ECG) alone or in combination with echocardiography in patients with acute pulmonary embolism and normal blood pressure.

Methods

Consecutive adult patients presenting to the emergency department at Azienda Ospedaliero-Universitaria Careggi with the first episode of pulmonary embolism were included. Patients with systolic blood pressure less than 100 mm Hg were excluded. ECG and echocardiography were performed within 1 hour from diagnosis and evaluated in a blinded fashion. Right ventricular strain was diagnosed in the presence of one or more of the following ECG findings: complete or incomplete right ventricular branch block, S1Q3T3, and negative T wave in V1-V4. The main outcome measurement was clinical deterioration or death during in-hospital stay. The association of variables with the main outcome was evaluated by multivariate Cox survival analysis.

Results

A total of 386 patients with proved pulmonary embolism were included in the study; 201 patients (52%) had right ventricular dysfunction according to echocardiography, and 130 patients (34%) showed right ventricular strain. Twenty-three patients (6%) had clinical deterioration or died. At multivariate survival analysis, right ventricular strain was associated with adverse outcome (hazard ratio 2.58; 95% confidence interval, 1.05-6.36) independently of echocardiographic findings. Patients with both right ventricular strain and right ventricular dysfunction (26%) showed an 8-fold elevated risk of adverse outcome (hazard ratio 8.47; 95% confidence interval, 2.43-29.47).

Conclusion

Right ventricular strain pattern on ECG is associated with adverse short-term outcome and adds incremental prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure.     

Electrocardiographic score and short-term outcomes of acute pulmonary embolism

Risk stratification of patients with a diagnosis of acute pulmonary embolism (PE) is crucial in deciding appropriate management. An electrocardiographic (ECG) scoring system may potentially be useful in identifying patients at high risk of increased hospital morbidity and mortality from acute PE. Electrocardiography and echocardiography of 159 patients with a diagnosis of acute PE using ventilation/perfusion scan or spiral computed tomographic scan at 2 Emory-affiliated hospitals were reviewed. The 21-ECG score was compared with the presence or absence of right ventricular (RV) dysfunction and the 2 major end points of complicated in-hospital course or death. ECG score was significantly higher in patients with RV dysfunction (p <0.001) and a complicated in-hospital course (p <0.05). Although the ECG score was higher in nonsurvivors, it was not significantly different. Based on receiver-operator characteristic curves, an ECG score > or =3 could predict RV dysfunction with sensitivity, specificity, and positive and negative predictive values of 76%, 82%, 76%, and 86%, respectively. An ECG score > or =3 could predict a complicated in-hospital course and mortality with sensitivities of 58% and 59%, specificities of 60% and 58%, positive predictive values of 16% and 10%, and negative predictive values of 89% and 95%, respectively. In conclusion, the current 21-ECG scoring system can predict RV dysfunction in patients with acute PE well. However; its ability to predict an adverse in-hospital course is limited. Nevertheless, an ECG score <3 predicts better short-term outcome in these patients.     

Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism.

OBJECTIVE: To investigate the prognostic value of echocardiographic findings in patients who present with symptoms suggestive of acute pulmonary embolism. DESIGN: 317 patients with clinically suspected pulmonary embolism were prospectively evaluated by echocardiography for the presence of right ventricular afterload stress and right heart or pulmonary artery thrombi. Objective confirmation of pulmonary embolism by lung scan or pulmonary angiography was obtained in 164 (52%). The presence of deep venous thrombosis was established in 90 of 158 patients (57%) who underwent phlebographic or Doppler sonographic studies. RESULTS: Right ventricular afterload stress was diagnosed in 87 patients (27%). Objective confirmation of pulmonary embolism and diagnosis of deep venous thrombosis was more common in patients with right ventricular afterload stress than in those without (83% v 40% and 46% v 22%, respectively; P < 0.001). This was also true for the detection of thrombi in the right heart and major pulmonary arteries (12 patients v 1 patient; P < 0.001) as well as for the in-hospital mortality from venous thromboembolism (13% v 0.9%; P < 0.001). One year mortality from pulmonary embolism was 13% in patients with right ventricular afterload stress at presentation compared with 1.3% in those without (P < 0.001). CONCLUSIONS: The presence of right ventricular afterload stress detected by echocardiography is a major determinant of short term prognosis in patients with clinically suspected acute pulmonary embolism.     

肌钙蛋白Ⅰ检测对急性肺栓塞患者的诊断和预后评估价值

急性肺栓塞(APE)发病率和病死率高,同时漏诊率和误诊率亦较高,能对APE进行快速的危险分层诊断和预后评估对指导临床治疗相当重要。研究表明肌钙蛋白Ⅰ可用于APE的危险分层诊断,并可作为APE的独立预后评估指标,且检查方法简单、快捷、经济,其在APE患者诊治中的临床价值越来越受到重视。