Pulmonary embolism: impact of right ventricular dysfunction

PURPOSE OF REVIEW: The appropriate treatment of patients with acute pulmonary embolism who present with right ventricular dysfunction but normal arterial blood pressure, and particularly the potential benefits of thrombolytic treatment in this setting, continue to be highly controversial. In the past year, several well designed studies improved our understanding of subclinical right ventricular dysfunction in pulmonary embolism, and emerging risk stratification algorithms now appear to identify high-risk patients reliably. RECENT FINDINGS: A meta-analysis confirmed that echocardiographically diagnosed right ventricular dysfunction is an independent predictor of early mortality in normotensive patients with pulmonary embolism. Retrospective studies suggest that similar information can also be obtained by multidetector-row chest computed tomography. Recent data indicate that biomarker (particularly troponin) testing followed by echocardiographic imaging of the right ventricle is an efficient and reliable strategy both for excluding (ruling out) and for predicting (ruling in) a poor outcome in patients with pulmonary embolism. SUMMARY: Novel risk stratification algorithms may help identify possible candidates for early thrombolytic treatment in pulmonary embolism and thus provide the background for a large international multicenter study that will hopefully resolve the 30-year-old debate on the benefits of thrombolysis in normotensive patients with pulmonary embolism and right ventricular dysfunction.     

Kommentar zu den ESC-Leitlinien ?Guidelines on Diagnosis and Management of Acute Pulmonary Embolism“

As many as 40,000 patients in Germany die of acute pulmonary embolism (PE) each year. The updated (2008) ESC guidelines emphasize the importance of adjusting management strategies to the clinical severity of PE, i.e. the death or complication risk in the acute phase. Haemodynamically unstable patients with suspected high-risk PE should undergo emergency CT pulmonary angiography (CTPA) or, alternatively, echocardiography. If PE is confirmed, thrombolysis or surgical embolectomy should be performed without delay. In normotensive patients (non-high-risk PE), diagnostic algorithms based on multi-detector CTPA are generally preferred. Initial anticoagulation includes low-molecular-weight heparin or fondaparinux. However, selected normotensive patients with right ventricular (RV) dysfunction and/or myocardial injury may benefit from early thrombolysis (intermediate-risk group). Oral anticoagulation for secondary prophylaxis should be continued for at least 3 months. In patients with unprovoked PE, stable INR and low bleeding risk, indefinite anticoagulation may be considered.     

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.     

Right ventricular dysfunction and ischemia in pulmonary embolism

Patients with pulmonary embolism and right ventricle dysfunction (determined with clinical, hemodynamic or echocardiographic methods) are a subgroup at high risk for complications. One of the pathogenic factors of right ventricular dysfunction in pulmonary embolism is myocardial ischemia, usually secondary to hemodynamic overload, and sometimes worsened by underlying coronary artery disease. We described a patient with pulmonary embolism and dyskinesia of the right ventricular free wall, related to chronic atherosclerotic occlusion of the right coronary artery proximal to the acute marginal branches that irrigate the free wall.     

The impact of right ventricular dysfunction on the prognosis and therapy of normotensive patients with pulmonary embolism

The prognosis and optimal therapy of patients with pulmonary embolism (PE) are strongly influenced by the presence or absence of associated hemodynamic derangements. Patients with normal systemic arterial pressure have a relatively low risk of recurrent PE and death when treated promptly with therapeutic anticoagulation. Those who present with hypotension, shock, or cardiac arrest, however, have a much higher mortality rate and often receive thrombolytic therapy. Recent evidence indicates that the presence of right ventricular (RV) dysfunction identifies a subgroup of normotensive patients with a much more guarded prognosis who may benefit from more intensive therapy with thrombolytic agents. This article reviews our current understanding of the pathophysiology and diagnosis of RV dysfunction and its impact on the prognosis and therapy of normotensive patients with PE.     

右室功能异常对血压正常肺栓塞预后影响

目的研究右心室功能异常对血压正常肺栓塞患者临床和预后的影响。方法2001年1月至2004年12月入住本院就诊时血压正常确诊肺栓塞患者,超声心动图检查右室扩张、肺动脉高压作为右室功能异常定量诊断标准。分为血压正常肺栓塞右室功能异常组和正常组,对临床情况进行回顾性分析。结果57例血压正常肺栓塞患者其中27例右室功能异常,30例右室功能正常。右室功能异常组与正常组肺栓塞相关病死率为19％比0％,差异有统计学意义。结论右室功能异常是增加肺栓塞病死率的一个重要因素。超声心动图能较好地评价右室功能状况,可识别出具有高度死亡危险性的人群。     

High Dose and Short-Term Streptokinase Infusion in Patients with Pulmonary Embolism: Prospective with Seven-Year Follow-Up Trial

Background: High dose and short-term streptokinase infusion has proved to improve survival among few patients with pulmonary embolism and cardiogenic shock, without increasing hemorrhagic complications. However its efficacy and safety in terms of long follow-up and in major number of patients requires to be established. Methods: Patients with pulmonary embolism proved through high probability V/Q lung scan, suggestive echocardiogram, or deep venous thrombosis were enrolled. All were assigned to receive 1,500,000 IU in one-hour streptokinase infusion. The primary end point was efficacy and safety of streptokinase regimen in terms of pulmonary arterial hypertension, right ventricular dysfunction, perfusion abnormalities, recurrence, mortality and hemorrhagic complications. In long-term follow-up, we assessed functional class, recurrence, chronic pulmonary arterial hypertension, postthrombotic-syndrome and mortality. Results: A total of 40 consecutive patients (47.3±15.3 years of age) with large or massive pulmonary embolism were enrolled. In 35 patients high dose and short-term streptokinase regimen reversed acute pulmonary arterial hypertension, clinical and echocardiographic evidence of right ventricular dysfunction and improved pulmonary perfusion without increasing hemorrhagic complications. In acute phase 5 patients died, necropsy study performed in 4 patients showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. Risk factors for mortality and recurrence were: right ventricular global hypokinesis (p<0.0001), 6 hours or over between onset symptoms and streptokinase regimen (p=0.02), severe systolic pulmonary arterial hypertension (p=0.001) right ventricular hypokinesis (p=0.001), hypoxemia (p=0.02) and right ventricular acute myocardial infarction (p<0.0001). Right ventricular hypokinesis (p=0.02) was the only independent risk factor for recurrence. In a seven-year follow-up of the original 35 patients who survived in acute phase, 2 patients were lost and 33 are alive, in functional class I, without recurrence or chronic pulmonary arterial hypertension. Conclusions: Our report indicates that among properly selected high-risk PE patients, short-term streptokinase infusion is effective and safe.     

Risk stratification of normotensive patients with acute symptomatic pulmonary embolism

Treatment guidelines recommend strong consideration of thrombolysis in patients with acute symptomatic pulmonary embolism (PE) that present with arterial hypotension or shock because of the high risk of death in this setting. For haemodynamically stable patients with PE, the categorization of risk for subgroups may assist with decision-making regarding PE therapy. Clinical models [e.g. Pulmonary Embolism Severity Index (PESI)] may accurately identify those at low risk of overall death in the first 3 months after the diagnosis of PE, and such patients might benefit from an abbreviated hospital stay or outpatient therapy. Though some evidence suggests that a subset of high-risk normotensive patients with PE may have a reasonable risk to benefit ratio for thrombolytic therapy, single markers of right ventricular dysfunction (e.g. echocardiography, spiral computed tomography, or brain natriuretic peptide testing) and myocardial injury (e.g. cardiac troponin T or I testing) have an insufficient positive predictive value for PE-specific mortality to drive decision-making toward such therapy. Recommendations for outpatient treatment or thrombolytic therapy for patients with PE necessitate further development of prognostic models and conduct of clinical trials that assess various treatment strategies.     

经抗凝治疗的非高危肺栓塞患者远期预后分析

目的 对经抗凝治疗的中危、低危肺栓塞患者进行随访,分析其远期预后,探讨影响预后的危险因素.方法 回顾性收集青岛大学附属医院自2010年1月至2015年1月初次诊断的424例非高危肺栓塞患者住院及门诊随访资料,电话随访患者出院后华法林应用情况、监测情况及临床转归,探讨其远期预后(死亡、再发深静脉血栓、慢性血栓栓塞性肺动脉高压和/或右心衰竭、抗凝后引起出血)差别并分析导致不良预后的危险因素.结果 随访424例中、低危肺栓塞患者,为期1.0~5.5年,失访41例,死亡65例.不同危险分层非高危肺栓塞患者远期预后差异有统计学意义(H=-5.261,P<0.05);不同危险分层间死亡、慢性血栓栓塞性肺动脉高压、出血及再发深静脉血栓差异有统计学意义(P值均<0.001).多因素logistic回归分析显示年龄(OR=1.029,95%CI:1.008~1.049)、恶性肿瘤(OR=6.300,95%CI:2.906~13.658)、右心功能不全(OR=4.058,95%CI:2.482~6.635)、隐源性肿瘤(OR=22.667,95%CI:2.298~223.537)为影响长期预后的危险因素.结论 非高危肺栓塞患者预后存在差异.高龄、恶性肿瘤、右心功能不全及隐源性肿瘤可能是影响非高危肺栓塞患者不良预后的主要危险因素.     

NT-proBNP与cTnⅠ在评估老年中高危肺栓塞合并右心功能障碍患者病情中的应用价值

目的 探讨血浆N末端B型利钠肽原(NT-proBNP)、心肌肌钙蛋白Ⅰ(cTnⅠ)在评估老年急性中高危肺栓塞合并右心功能障碍患者病情中的应用价值.方法 选取2015年1月至2016年6月新疆医科大学第一附属医院收治的老年急性中高危肺栓塞合并右心功能障碍的59例患者作为合并组,另选取85例未发生右心功能障碍的老年急性中高危肺栓塞患者作为非合并组,以及50名体检健康者作为对照组.采集所有研究对象清晨空腹外周静脉血,应用免疫荧光法测定患者血浆NT-proBNP及cTnⅠ指标,采集血液标本的同时进行超声心动图检查,对比各组NT-proBNP、cTnⅠ指标的差异性,并应用特征曲线分析影响急性中高危肺栓塞患者临床预后结局的主要因素.结果 3组NT-proBNP、cTnⅠ指标比较差异均有统计学意义(P值均＜0.05),并且合并组患者右心室舒张末期内径明显高于非合并组与对照组(P值均＜0.05).受试者工作特征曲线显示NT-proBNP、cTnⅠ曲线下面积均大于90％,logistic回归分析显示NT-proBNP、cTnⅠ指标、右心功能障碍与患者临床预后具有密切联系.结论 NT-proBNP、cTnⅠ指标不仅在诊断急性中高危肺栓塞合并右心功能障碍中具有重要意义,同时能够对患者的临床预后转归提供良好、准确的评估,可作为指导肺栓塞患者临床治疗的简单、灵敏的标志物.     

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.     

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.     

Troponin levels as a guide to treatment of pulmonary embolism

Right ventricular dysfunction in hemodynamically stable patients with acute pulmonary embolism may be a harbinger of adverse outcomes and may potentially result in the early use of thrombolytic therapy. Risk stratification of these patients is an area of recent and intense investigation with a focus on the assessment of right ventricular function after the embolic event. Echocardiography has been used to identify right ventricular dysfunction but is potentially hampered by a number of limitations. With the onset of right ventricular dilation and possible ischemia in acute pulmonary embolism, elevated serum troponins may be an early and reliable marker of right ventricular dysfunction. In acute pulmonary embolism, both right ventricular dysfunction by echocardiogram and elevated troponin levels have been shown to predict an adverse outcome. Therefore, serum troponin levels should help stratify patients with submassive acute pulmonary embolism into a group in which aggressive medical or surgical intervention would be considered.     

Heart-type fatty acid-binding protein permits early risk stratification of pulmonary embolism.

AIMS: We investigated the value of a novel early biomarker, heart-type fatty acid-binding protein (H-FABP), in risk stratification of patients with acute pulmonary embolism (PE). METHODS AND RESULTS: We prospectively included 107 consecutive patients with confirmed PE. The endpoints were (i) PE-related death or major complications and (ii) overall 30-day mortality. Overall, 29 patients (27%) had abnormal (>6 ng/mL) H-FABP levels at presentation. Of those, 12 (41%) had a complicated course, whereas all patients with normal baseline H-FABP had a favourable 30-day outcome (OR, 71.45; P<0.0001). At multivariable analysis, H-FABP (P<0.0001), but not cardiac troponin T (P=0.13) or N-terminal pro-brain natriuretic peptide (P=0.36), predicted an adverse outcome. Evaluation of a strategy combining biomarker testing with echocardiography revealed that patients with a negative H-FABP test had an excellent prognosis regardless of echocardiographic findings. In contrast, patients with a positive H-FABP test had a complication rate of 23.1% even in the presence of a normal echocardiogram, and this rose to 57.1% if echocardiography also demonstrated right ventricular dysfunction (OR vs. a negative H-FABP test, 5.6 and 81.4, respectively). CONCLUSION: H-FABP is a promising early indicator of right ventricular injury and dysfunction in acute PE. It may help optimize risk stratification algorithms and treatment strategies.     

Acute pulmonary embolism: risk stratification in the emergency department

Pulmonary embolism is a common disease associated with a high mortality rate. Death due to pulmonary embolism occurs more commonly in undiagnosed patients before hospital admission or during the initial in-hospital stay. Thus, mortality could be reduced by prompt diagnosis, early prognostic stratification and more intensive treatment in patients with adverse prognosis. Mortality is particularly high in patients with pulmonary embolism presenting with arterial hypotension or cardiogenic shock. In patients with pulmonary embolism and normal blood pressure, a number of clinical features and objective findings have been associated with a high risk of adverse in-hospital outcome. Advanced age and concomitant cardiopulmonary disease are clinical risk factors for in-hospital mortality. The Bburden of thromboembolism, as assessed by lung scan or spiral CT, and right ventricle overload, as assessed by echocardiography and probably spiral CT, have been claimed to be risk factors for in-hospital mortality. Elevated serum levels of troponins have been shown to be associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism. Despite the currently available evidence, no definite prognostic value can be assigned to any of the individual risk factors or cluster of them. Large prospective trials should be carried out to validate individual risk factors or clusters of risk factors able to identify patients with acute pulmonary embolism at high risk for in-hospital mortality. These patients could afford the trade-off of an increased risk of side effects related to a more aggressive treatment, such as thrombolysis or surgical or interventional procedures.     

Pulmonary Embolism with Right Ventricular Dysfunction: Who Should Receive Thrombolytic Agents?

Background

Appropriate management of pulmonary embolism patients with right ventricular dysfunction is uncertain. Recent guidelines have stressed the need for more data on the use of thrombolytic agents in the stable pulmonary embolism patient with right ventricular dysfunction. The objective of this study is to investigate the hypothesis that thrombolytic therapy in hemodynamically stable pulmonary embolism patients with right ventricular dysfunction is not associated with improved mortality.

Pulmonary complications of transcatheter arterial chemoembolization for hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) is an effective palliative intervention that is widely accepted for the management of hepatocellular carcinoma (HCC). Post-TACE pulmonary complications resulting in acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) are rare events. Pulmonary complications after TACE are thought to be related to chemical injury subsequent to the migration of the infused ethiodized oil or chemotherapeutic agent to the lung vasculature, facilitated by arteriovenous (AV) shunts within the hyper-vascular HCC. We review herein the literature on pulmonary complications related to TACE for HCC. Post-TACE pulmonary complications have included pulmonary oil embolism, interstitial pneumonitis, chemical pneumonitis, ALI, ARDS, lipoid pneumonia, acute eosinophilic and neutrophilic pneumonia, bilious pleuritis, pulmonary abscess, pulmonary tumor embolism, and possibly pulmonary metastasis with HCC. The risk factors associated with post-TACE pulmonary complications identified in the literature include large hyper-vascular HCC with AV shunts, large-volume Lipiodol infusion, and embolization via the right inferior phrenic artery. However, the absence of known risk factors is not a guarantee against serious complications. An astute awareness of the potential post-TACE pulmonary complications should expedite appropriate therapeutic interventions and increase potential for early recovery.     

Acute fatal pulmonary embolism: its prevention, diagnosis and treatment

Acute fatal pulmonary embolism is one cause of sudden death which should be guarded against. It is the most often missed diagnosis in sudden death cases within the hospital. Clinical pictures of 10 patients with acute fatal pulmonary embolism proved by autopsy were examined to elucidate the problems of diagnosis, and to look for an effective treatment, and a method of prevention. Common risk factors were old age and immobility due to stroke or postoperative state. Common past histories were hypertension, diabetes mellitus, obesity, atrial fibrillation and hyperlipidemia. Electrocardiogram and echocardiogram showed that in these patients there was definite evidence of acute right ventricular overload. High doses of intravenous urokinase should be given whenever acute cardiovascular collapse develops in such high risk patients. Emergent pulmonary angiogram and pulmonary embolectomy could be life-saving in patients with acute massive pulmonary embolism. Prevention is, however, the best treatment. In addition to anticoagulation medication, frequent change of body position and early mobilization are important precautions to prevent fatal pulmonary embolism developing in such patients.     

Combined clot fragmentation and aspiration in patients with acute pulmonary embolism

BACKGROUND: Massive angiographic pulmonary embolism (PE) with right ventricular dysfunction (RVD) is associated with a high early mortality rate. The therapeutic alternatives for this condition include thrombolysis, surgical embolectomy, or percutaneous mechanical thrombectomy (PMT). We describe our experience using PMT in patients with massive PE and RVD with unsuccessful thrombolysis, increased bleeding risk, or major contraindications for thrombolytic therapy. METHODS: Clinical, hemodynamic, and angiographic parameters prior to and following PMT were evaluated. Our primary objective was to describe the incidence of in-hospital cardiovascular death, and of major and minor complications. Mid-term outcomes included analysis of occurrence of cardiovascular death, recurrent pulmonary embolism, change of New York Heart Association functional class, and hospital readmission. RESULTS: From July 2004 to May 2007, 69 patients were referred to the cardiac catheterization laboratory with a diagnosis of acute PE, 18 of whom met the criteria for massive PE and are the subject of this study. All patients underwent thrombus fragmentation using a pigtail catheter that was complemented in 13 patients with thrombus aspiration. A percutaneous thrombectomy device (Aspirex; Straub Medical; Wangs, Switzerland) was used in 11 patients. Hemodynamic, angiographic, and blood oxygenation parameters improved after the procedure. A significant increase was observed for systolic systemic BP (74.3+/-7.5 mm Hg vs 89.4+/-11.3 mm Hg, p=0.001) [mean+/-SD], as was a decrease in mean pulmonary artery pressure (37.1+/-8.5 mm Hg vs 32.3+/-10.5 mm Hg , p=0.0001). The in-hospital major complications rate was 11.1%; one patient died from refractory shock, and one patient had intracerebral hemorrhage with minor neurologic sequelae. No cardiovascular deaths or recurrent pulmonary thromboembolism were documented during clinical follow-up (12.3+/-9.4 months). CONCLUSIONS: In patients with massive PE, RVD and major contraindications to thrombolytic therapy, increased bleeding risk, failed thrombolysis, or unavailable surgical thrombectomy, PMT appears to be a useful therapeutic alternative.     

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.