Atrial and ventricular echocardiographic correlates of the extent of pulmonary embolism in the elderly

Left Atrial Phasic Function Impairment in Subacute and Chronic Pulmonary Embolism Patients With Different Degrees of Obstruction: An MRI Feature Tracking Study

BACKGROUND

The alteration of left atrial (LA) phasic function in subacute and chronic pulmonary embolism (PE) patients is unclear.

PURPOSE

To investigate LA phasic strain and LA-right ventricular (RV) interaction in subacute and chronic PE patients with different degrees of obstruction by MRI-feature tracking (MRI-FT).

STUDY TYPE

Retrospective.

POPULATION

One hundred three PE patients (54 subacute [2 weeks to 3 months after initial symptoms], 49 chronic [>3 months after initial symptoms]) and 80 controls.

FIELD STRENGTH/SEQUENCE

3.0 T/balanced steady state free precession sequence.

ASSESSMENT

Patients were divided into mild (pulmonary artery obstruction index [PAOI] < 30%, N = 57), moderate (30% ≤ PAOI < 50%, N = 27), and severe (50% ≥ PAOI, N = 19) PE subgroups. LA reservoir, conduit, and active pump longitudinal strains (εs, εe, and εa) and strain rates (SRs, SRe, and SRa) and biventricular global strains were measured. Determinants of LA strains were investigated.

STATISTICAL TESTS

ANOVA, t-tests, Mann-Whitney U tests, linear regression. P < 0.05 was considered statistically significant.

RESULTS

For both subacute and chronic PE patients, LA reservoir, conduit, and active pump strains and strain rates were significantly lower than in controls. However, there were no significant differences in LA strains between patients with subacute and chronic PE (P = 0.933, 0.625, and 0.630 for εs, εe, and εa). The severe PE subgroup had significantly higher εa and SRa than the mild and moderate PE subgroups. LA strains were significantly correlated with RV diameter and biventricular strains, and RV diameter (β = -6.836, -4.084, and -1.899 for εs, εe, and εa) was independently associated with LA strains after adjustment for other factors (R2 = 0.627, 0.536, and 0.437 for εs, εe, and εa).

DATA CONCLUSION

LA phasic function evaluated by MRI-FT was significantly impaired in subacute and chronic PE patients, and LA active pump function in the severe PE subgroup was higher than that in the mild and moderate PE subgroups. The independent association between RV diameter and LA strains demonstrates that RV diameter may be an important indicator for monitoring LA dysfunction in PE patients.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 3.

Pulmonary Embolism in the Elderly: From Symptoms to Speckle Tracking Echocardiography

(1) Background: There are little data about the differences in clinical and echocardiographic characteristics between elderly (aged ≥ 65 years) and younger patients with acute pulmonary embolism (PE). (2) Methods: Consecutive patients diagnosed with PE in a tertiary hospital were identified. Clinical characteristics, biomarkers and transthoracic echocardiography indices including right ventricular free wall longitudinal strain (RV-FWLS) were recorded. (3) Results: Of 200 patients enrolled, 19 patients had high-risk PE and were excluded from the study. Compared to younger patients, elderly patients with PE had less frequently pain and typical symptoms and more often were hospitalized due to another reason before the PE diagnosis. The elderly had higher values of D-dimer, high-sensitivity troponin I and brain natriuretic peptide (BNP). Echocardiographic differences were noted and the elderly had lower values of pulmonary vascular acceleration time, RV E/A ratio and lower tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio. The RV-FWLS index did not show a statistically significant difference in distribution between age groups ≥ 65 and <65 years old. The RV diameter was similar across all age groups. (4) Conclusions: The elderly have differences compared with younger patients with PE regarding the mode of presentation, the values of biomarkers like D-dimer, BNP and troponins and some echocardiographic indices of RV affection.

Alterations and Significance of Computed Tomography Pulmonary Angiography-Derived Parameters in Older Patients With Acute Pulmonary Embolism

OBJECTIVE

This study aimed to investigate changes of computed tomography pulmonary angiography (CTPA)-derived parameters in older adults with acute pulmonary embolism (APE).

METHODS

According to the pulmonary artery obstruction index (PAOI), patients with APE were divided into the A1 (PAOI ≥30%, n = 57) and A2 (PAOI <30%, n = 40) groups. Participants without APE were placed in group B (n = 170). The left atrial (LA) and left ventricular (LV) parameters among the three groups were compared, and the parameter changes in the 44 patients with APE were analyzed before and after treatment. The correlation between APE severity and the parameters was analyzed using correlation analysis.

RESULTS

The left-to-right diameters (LR) of LA, and LR × anteroposterior diameters (AP) of LA and LV: A1 < A2 < B; LR of LV: A1 < A2, B; AP of LA and LV: A1, A2 < B. After treatment, LR and LR × AP of the LA and LV were significantly increased in the group A1 and LR of the LV and LR × AP of the LA and LV were elevated in the group A2. Acute pulmonary embolism severity was closely associated with LR × AP ( r = -0.557) and LR ( r = -0.477) of LA.

CONCLUSIONS

With an increase in the degree of obstruction, older adults had a smaller LA and LV. Furthermore, the LR and LR × AP values of the LA were significantly decreased. These results contribute to in-time risk stratification.

Left atrium volume and ventricular volume ratio algorithm as indication of pulmonary hypertension etiology

BACKGROUND

Pressure overload of the right heart (pulmonary hypertension [PH]) can be an acute or a chronic process with various pathophysiologic changes affecting the dimensions of the heart chambers. The automatic four-chamber volumetric analysis tool is now available to measure the volume of the cardiac chambers in patients undergoing a computed tomography pulmonary angiogram (CTPA).

PURPOSE

To characterize the volumetric changes that occurred in response to increased systolic pulmonary arterial pressures (sPAP) in acute events, such as acute pulmonary embolism (APE), compared with other etiologies.

MATERIAL AND METHODS

Consecutive patients who underwent CTPA and echocardiography within 24 h between 2011 and 2015 were included. Differences in cardiac chamber volumes were investigated in correlation to the patients' sPAP.

RESULTS

The final cohort of 961 patients included 221 (23%) patients diagnosed with APE. The right (RV) to left (LV) ventricular volume ratio (VVR) was higher, while the left atrial (LA) volume index was smaller (P < 0.001) in the patients with APE. A decision tree for the prediction of APE showed that an RV to left VVR >2.8 was characteristic of APE, whereas an LA volume index >37.5 mL/m² was more compatible with PH due to other etiologies (P < 0.001).

CONCLUSION

The combination of VVR and LA volume index may help in differentiating between APE and chronic PH. CTPA-based volumetric information may be used to help clarify the underlying etiology of the dyspnea.

Differences in clinical and echocardiographic variables and mortality predictors among older patients with pulmonary embolism

BACKGROUND

An increase in short-term mortality can be found among older patients with hemodynamically stable acute pulmonary embolism (APE) who have signs of right ventricular (RV) dysfunction.

AIMS

This study was designed to assess whether any difference exists among clinical, laboratory, electrocardiography and echocardiography parameters between older and younger patients diagnosed with APE.

METHODS

The study sample included a total of 635 patients with confirmed APE who were divided into two groups of older (65 years and older) and younger (younger than 65 years) individuals. Comparisons were performed between these groups in terms of clinical, predisposing factors and laboratory, electrocardiographic and echocardiographic parameters.

RESULTS

Analyses of 295 (46.4%) older and 340 (53.6%) younger patients diagnosed with APE were performed. Female sex, Pulmonary Embolism Severity Index score and baseline creatinine levels were higher in the older group. Also, the frequency of atrial fibrillation, RV outflow tract parasternal long-axis proximal diameter, RV end-diastolic diameter (RV-EDD) basal (apical four-chamber) and RV systolic pressure were significantly greater in older patients with APE. A total of 30 (4.7%) deaths were observed during the in-hospital period [21 (7.1%) older vs 9 (2.6%) younger patients; p < 0.01]. In the multivariate logistic regression analysis, age, white blood cell count (WBC), left ventricular ejection fraction (LVEF), RV-EDD basal and tricuspid annular plane systolic excursion (TAPSE) of less than 16 mm were found to be independently associated with in-hospital mortality.

CONCLUSION

Older patients might experience greater rates of RV dilatation, RV dysfunction and atrial fibrillation during APE. In addition to age; elevated WBC, low LVEF, increased RV-EDD basal and TAPSE of less than 16 mm were independent predictors of mortality among study population.

Prognostic value of right atrial dilation in patients with pulmonary embolism

Aims

Right atrial (RA) dilation and stretch provide prognostic information in patients with cardiovascular diseases. We investigated the prevalence, confounding factors and prognostic relevance of RA dilation in patients with pulmonary embolism (PE).

Methods

Overall, 609 PE patients were consecutively included in a prospective single-centre registry between September 2008 and August 2017. Volumetric measurements of heart chambers were performed on routine non-electrocardiographic-gated computed tomography and plasma concentrations of mid-regional pro-atrial natriuretic peptide (MR-proANP) measured on admission. An in-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration.

Results

Patients with an adverse outcome (11.2%) had larger RA volumes (median 120 (interquartile range 84-152) versus 102 (78-134) mL; p=0.013), RA/left atrial (LA) volume ratios (1.7 (1.2-2.4) versus 1.3 (1.1-1.7); p<0.001) and MR-proANP levels (282 (157-481) versus 129 (64-238) pmol·L^-1; p<0.001) compared to patients with a favourable outcome. Overall, 499 patients (81.9%) had a RA/LA volume ratio ≥1.0 and a calculated cut-off value of 1.8 (area under the curve 0.64, 95% CI 0.56-0.71) predicted an adverse outcome, both in unselected (OR 3.1, 95% CI 1.9-5.2) and normotensive patients (OR 2.7, 95% CI 1.3-5.6). MR-proANP ≥120 pmol·L^-1 was identified as an independent predictor of an adverse outcome, both in unselected (OR 4.6, 95% CI 2.3-9.3) and normotensive patients (OR 5.1, 95% CI 1.5-17.6).

Conclusions

RA dilation is a frequent finding in patients with PE. However, the prognostic performance of RA dilation appears inferior compared to established risk stratification markers. MR-proANP predicted an in-hospital adverse outcome, both in unselected and normotensive PE patients, integrating different prognostic relevant information from comorbidities.

Decreased pulmonary artery distensibility as a marker for severity in acute pulmonary embolism patients undergoing ECG-gated CTPA

To investigate the characteristics of pulmonary artery distensibility (PAD) in patients with acute pulmonary embolism (APE) and to assess whether a relationship exists between PAD and the disease severity. Clinical and radiological data of 30 APE patients who underwent retrospective electrocardiogram (ECG)-gated computed tomography pulmonary angiography (CTPA) with a definite diagnosis of APE were retrospectively reviewed in the present study, including 15 subjects in severe (SPE) group and 15 subjects in non-severe (NSPE) group. PAD and cardiac function parameters were compared between the two groups, their relationships were investigated, and receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of the above parameters for the diagnosis of APE severity. The PAD decreased in the following order: NSPE group (6.065 ± 2.114) × 10^-3 (%/mmHg), and SPE group (4.334 ± 1.777) × 10^-3 (%/mmHg) (P < 0.05). All the cardiac function parameters except RA/LAdiameter showed statistically significant different values between the two groups (P < 0.05). As APE severity increased, the cardiac morphological measurements of RV/LVdiameter, RV/LVarea, RVEDV/LVEDV and RVESV/LVESV increased. There was a weak to moderate negative correlation between PAD and PAmax, PAmin, PA/AAmin, PA/AAmax, RV/LVdiameter, RV/LVarea (r = -0.393 to -0.625), that is, PAD was inversely correlated with cardiac function parameters. There was a moderate negative correlation between PAD and hemoptysis(r = -0.672). The area under the ROC curve (AUC) of PAD was 0.724, the critical value was 4.137 × 10^-3  mm/Hg, and the sensitivity and specificity were 60.0% and 93.3%, respectively. PAmin showed the strongest discriminatory power to identify high-risk patients (AUC = 0.827), with the highest sensitivity of 100%, which was also achieved by RA/LAarea. The PAD obtained by retrospective ECG-gated CTPA could be an indicator to be used in the evaluation of the presence and severity of APE.

Association between 2D echocardiographic right atrial volume to left atrial volume (RAV/LAV) ratio and in-hospital prognosis in thrombolysed acute pulmonary thromboembolism patients

Right atrial volume/Left atrial volume (RAV/LAV) ratio is a good hemodynamic parameter in acute pulmonary thromboembolism (PTE), whose prognostic ability by 2D echocardiography is not studied to date. We conducted a 27 month, prospective observational study on 55 eligible acute PTE thrombolysed (29: Tenecteplase; 26: Streptokinase) patients. The primary endpoint was a composite of in-hospital death and poor right ventricular reverse remodelling at the time of discharge. The incidence of primary end-point and death were 40% and 7.2% respectively. On regression analysis, RAV/LAV ratio was the only predictor of the primary endpoint, with an optimal cut-off of 3.8 (accuracy 75%).

Left atrial size measured on CT pulmonary angiography: another parameter of pulmonary embolism severity? A systematic review

We systematically review the potential role of left atrial (LA) size, evaluated at computed tomography angiography (CTA) in patients with acute pulmonary embolism (PE), as a new parameter of PE severity. A literature search based on PubMed (MEDLINE), Scopus, Cochrane library and Google Scholar databases was performed to locate previous published investigations reporting data on the severity of acute PE based on the evaluation of LA size (either volume, diameter or area). Six studies, corresponding to a total of 990 patients, published between 2012 and 2019 were included into the analysis. The severity of acute PE, in terms of hemodynamic impairment, increases with the reduction of the LA volume and a significant negative correlation was observed between the pulmonary artery obstruction index (PAOI) and the LA area. Similarly, the longest left-to-right as well as the anteroposterior diameters of the LA had a significant positive correlation with the PAOI index for both the measurement. The LA volume significantly decreased with the increasing of the PAOI index. Moreover, a lower LA volume was observed in those subjects with a saddle PE appearing as the best single parameter able to discriminate between patients having or not a saddle acute PE. Intriguingly, PE patients died within 30 days from the acute event had a significant small LA volume compared to survivors. Data obtained from the current medical literature seem to suggest that the evaluation of LA size evaluation could be a new parameter of PE severity. Further and larger prospective studies are needed to confirm preliminary findings.

Lipocalin-type prostaglandin D synthase levels are associated with the severity of pulmonary embolism

Pulmonary thromboembolism (PTE) is an acute emergency with high mortality and morbidity rates. This study aimed to investigate the importance of Lipocalin-type prostaglandin D synthase (L-PGDS) in predicting mortality and prognosis in PTE. The study prospectively included 90 patients who were admitted to the emergency department and in whom PTE was confirmed by computed tomographic pulmonary angiography as well as 40 healthy volunteers with no disease. L-PGDS levels in the venous blood were measured and compared. Pulmonary embolism severity index (PESI) prognosis scores of all patients and 1-month mortality rate were calculated. There was a statistically significant difference between the L-PGDS levels of the patient and control groups (P = 0.024), and 1-month mortality of patients diagnosed with PTE was 20% (n = 18). Furthermore, the patients were divided into two groups: patients deceased within 1 month following the diagnosis and survivors. L-PGDS levels of the deceased patients were significantly higher than those of the survivors (P < 0.001). Age, systolic blood pressure, pulse, shock index, lactate, and PESI scores were significantly different between the survivors and deceased patients. The cut-off value for L-PGDS obtained using receiver operating characteristic (ROC) curve analysis for 1-month mortality was 815.26 ng/mL (sensitivity: 83.33%; specificity: 79.17%; area under the curve: 0.851; 95% confidence interval 0.760-0.917; P < 0.001). Based on this cut-off value, logistic regression analysis revealed that increased L-PGDS, together with PESI, was an independent indicator of 1-month mortality. L-PGDS is associated with short-term mortality in patients with PTE; therefore, it can be used to predict mortality risk in patients with PTE.

Vector velocity imaging echocardiography to study the effects of submassive pulmonary embolism on the right atrium

OBJECTIVES

To assess the effects of submassive pulmonary embolism (SMPE) on right atrial (RA) anatomy and function.

BACKGROUND

Right ventricular dysfunction (RVD) is associated with adverse outcomes in SMPE. However, the effects of SMPE on the structure and function of the RA have received much less attention.

METHODS

Fifty patients with SMPE documented by CT angiography (SMPE group) and evidence of RVD on two-dimensional echocardiography were retrospectively identified and compared to 50 controls (control group). Both RA and RV areas, volumes and fractional area change (FAC) were measured. Pulmonary artery systolic pressures were estimated. RA and RV longitudinal strains were obtained using vector velocity imaging (VVI).

RESULTS

Compared with controls, RA and RV FACs were significantly reduced and associated with higher chamber volumes in the SMPE group. Global longitudinal RA strain was reduced in the SMPE group (29% + 11% vs 55% + 16%; P < .01), as was global RV longitudinal strain (-12% + 5% vs -20% + 5%, P < .01), when compared to the controls. A linear relationship existed between RV and RA strain in both groups; however, the curve was shifted downward among those with SMPE. Furthermore, ROC curve analysis suggests RA area performs better than RV area as a marker of SMPE.

CONCLUSIONS

RA structure and function are adversely affected in SMPE, similar to the effects observed in RV. Lower RA strain appears to be a novel quantitative indicator of SMPE, and RA area may be a more sensitive marker of this condition and may provide additional prognostic information in this condition.

Automated volumetric analysis of four cardiac chambers in pulmonary embolism

Identification of patients with acute pulmonary embolism (PE) who might be at risk of circulatory collapse by using a fast, automated system is highly desired. It was our objective to investigate whether automated cardiac volumetric analysis following computerised tomographic pulmonary angiography (CTPA) is useful to identify increased clot load and adverse prognosis in patients with acute PE. We retrospectively analysed a consecutive series of non-gated CTPA studies of 124 patients with acute PE and 43 controls. Right and left ventricular diameters (RV/LV) were measured on four-chamber view, while each cardiac chamber underwent automatic volumetric measurements. Findings were correlated to the pulmonary arterial obstruction index (PAOI). Outcome was expressed by admission to an intensive care unit (ICU) or mortality within 30 days. There was a significant positive correlation between the PAOI and the volumes of the right side cavities (r=0.25 for the atrium and r=0.49 for the ventricle), and between the right-to-left atrial and ventricular volume ratios (r=0.49 and r=0.57, respectively). Results for the combined outcome of mortality or ICU admission that fell in the upper tertile of the right atrial and right ventricular volumes yielded hazard ratios of 3.9 and 3.3, respectively, compared to those in the lower tertile. RV/LV diameter ratio did not correlate with outcome. In conclusion, adverse outcome and significant pulmonary clot load in patients with acute PE are associated with a volume shift towards right heart cavities, which correlates to prognosis better than the CT-measured RV/LV diameter ratio, suggesting the advantage of using fast fully automatic volumetric analysis to identify patients at risk.

Relative risk of pulmonary embolism in the very elderly compared with the elderly

BACKGROUND

Pulmonary embolism (PE) can be an acute, life-threatening emergency, and studies suggest that advanced age is a risk factor for this condition. However, the literature is scarce regarding PE in patients above the age of 90 years. This study examined the relative risk for PE in the very elderly (>90 years) compared with that in the elderly (80-89 years).

METHODS

A retrospective study was performed examining very elderly patients diagnosed with PE in the Department of Internal Medicine at the University Hospital Homburg/Saar in Germany between 2004 and 2012. Elderly patients (aged 80-89 years) diagnosed with PE served as controls. PE was confirmed by contrast-enhanced chest computed tomography or ventilation perfusion scintigraphy in both groups. A total of 2230 patients were examined for PE in this study. Of these, 15 (0.67%) in the study group and 197 (8.83%) in the control group underwent further evaluation for PE.

RESULTS

After performing a radiological examination, 11 (73.3%, including six [54.55%] women) of the 15 study patients (mean age 91.6 ± 1.67 years) and 148 (75.1%, including 93 [62.84%] women) of the 197 controls (mean age 84.0 ± 2.59 years) were confirmed to have PE. There was a significantly lower proportion of the very elderly enrolled in the study (P < 0.001). There were no significant differences in clinical presentation, cardiovascular risk factors, electrocardiograms, blood gas analyses, radiological diagnoses, or acute comorbidities between the groups. However, the very elderly were more likely to experience minor bleeding in the extremities (P = 0.016) and to have more chronic diseases (P < 0.001). An increased relative risk of PE was not detected in the very elderly (relative risk 0.98, P = 0.88). Furthermore, D-dimer, troponin T, and high-sensitive troponin T levels had limited predictive value for PE in the very elderly. There were no significant differences in the number of hospital admissions, intensive care or ward treatments, or duration of hospitalization.

CONCLUSION

The relative risk for PE in the very elderly is not higher than that in the elderly.

Right atrial to left atrial area ratio on early echocardiography predicts long-term survival after acute pulmonary embolism

BACKGROUND

Current guidelines recommend that transthoracic echocardiography (TTE) should be performed for acute risk stratification following acute pulmonary embolism (PE), but it is unclear whether the initial TTE can predict long-term outcome beyond six months. We sought to assess the potential of the initial right atrial (RA) to left atrial (LA) area ratio (RA/LA ratio) on TTE to predict long-term mortality in survivors of submassive PE.

METHODS

A derivation cohort comprised a previously reported group of 35 consecutive patients with acute PE who were intensively studied by serial TTE at 1, 2, 5 days, 2, 6, 12 and 26 weeks and RA/LA ratio related to long-term outcome. The Day 1 RA/LA ratio findings were then further related to long-term outcome in 158 patients followed for 3.6 ± 2.3 years.

RESULTS

In the derivation cohort, total mortality was 28.6% (n = 10) following a mean (±standard deviation) follow-up of 4.3 ± 1.9 years. The RA/LA ratio was highly dynamic, being increased at day 1, but normalised rapidly within 2-5 days of presentation and this was most marked amongst long-term non-survivors. A RA/LA ratio > 1.0 on day 1 was independently associated with a three-fold increase in long-term mortality on Kaplan-Meier analysis. Pooled analysis of 158 patient indicated that age, Charlson Comorbidity Index (CCI), simplified Pulmonary Embolism Severity Score (PESI), troponin T, day 1 RA/LA Ratio and pulmonary arterial systolic pressure (PASP) were univariate predictors of long-term mortality. Multivariate analysis identified Day 1 RA/LA Ratio (HR 1.7 per 10% increase, p = 0.002), CCI (HR 2.2 per 1 unit increase, p = 0.004) and age (HR 1.1, p = 0.03) as the only independent predictors of long-term mortality.

CONCLUSION

A RA/LA Ratio >1.0 at presentation with acute PE was associated with a three-fold increased risk of long-term mortality. The RA/LA ratio on presentation with an acute PE is a simple, novel predictor of long-term survival.

The association between the embolic load and atrial size in acute pulmonary embolism

BACKGROUND

Early identification by computed tomography pulmonary angiography (CTPA) of patients with acute pulmonary embolism (PE) who have signs associated with a high embolic burden would be highly desirable.

OBJECTIVES

To investigate whether an increased obstruction of the pulmonary vasculature is associated with reduced left atrial (LA) and increased right atrial (RA) areas.

METHODS

We retrospectively analyzed a consecutive series of CTPA studies of 137 patients with acute PE and 38 controls without PE between October 2004 and March 2006. Left and right atrial areas and longitudinal and short axis diameters were measured and correlated with the pulmonary arterial obstruction index (PAOI) divided into tertiles (obstruction of < 12.5%, 12.5%-42.5% and ≥ 42.5%).

RESULTS

There was a significant negative age- and gender-adjusted correlation between the PAOI and LA measurements, particularly the LA area (r = -0.259) and the LA short axis diameter (r = -0.331). All RA measurements had positive correlations (RA area, r = 0.279; RA short axis diameter, r = 0.313). The LA/RA area ratio correlated negatively with the PAOI (r = -0.447). All above-mentioned correlations had P < 0.002. All the LA measurements were the largest in the controls and gradually decreased with higher PAOIs. A receiver operating characteristic curve analysis demonstrated that the RV/LV diameter, LA/RA area and LA/RA short axis diameter ratios had comparable discriminative ability for higher PAOI tertiles.

CONCLUSIONS

The higher the clot load in the pulmonary arteries, the smaller the LA area and the larger the RA area. Atrial area measurements by CTPA may serve as a real-time parameter in assessing the severity of PE upon diagnosis.

Electrocardiography patterns and the role of the electrocardiography score for risk stratification in acute pulmonary embolism

Background and Objectives

Data on the usefulness of a combination of different electrocardiography (ECG) abnormalities in risk stratification of patients with acute pulmonary embolism (PE) are limited. We thus investigated 12-lead ECG patterns in acute PE to evaluate the role of the ECG score in risk stratification of patients with acute PE.

Subjects and Methods

One hundred twenty-five consecutive patients (63±14 years, 56 men) with acute PE who were admitted to Kyungpook National University Hospital between November 2001 and January 2008 were included. We analyzed ECG patterns and calculated the ECG score in all patients. We evaluated right ventricular systolic pressure (RVSP) (n=75) and RV hypokinesia (n=80) using echocardiography for risk stratification of acute PE patients.

Results

Among several ECG findings, sinus tachycardia and inverted T waves in V_1-4 (39%) were observed most frequently. The mean ECG score and RVSP were 7.36±6.32 and 49±21 mmHg, respectively. The ECG score correlated with RVSP (r=0.277, p=0.016). The patients were divided into two groups {high ECG-score group (n=38): ECG score >12 and low ECG-score group (n=87): ECG score ≤12} based on the ECG score, with the maximum area under the curve. RV hypokinesia was observed more frequently in the high ECG-score group than in the low ECG-score group (p=0.006). Multivariate analysis revealed that a high ECG score was an independent predictor of high RVSP and RV hypokinesia.

Conclusion

Sinus tachycardia and inverted T waves in V_1-4 were commonly observed in acute PE. Moreover, the ECG score is a useful tool in risk stratification of patients with acute PE.

Pulmonary embolism in the elderly: a review on clinical, instrumental and laboratory presentation

Objective

Diagnosis of pulmonary embolism (PE) remains difficult and is often missed in the elderly due to nonspecific and atypical presentation. Diagnostic algorithms able to rule out PE and validated in young adult patients may have reduced applicability in elderly patients, which increases the number of diagnostic tools use and costs. The aim of the present study was to analyze the reported clinical presentation of PE in patients aged 65 and more.

Materials and Methods

Prospective and retrospective English language studies dealing with the clinical, instrumental and laboratory aspects of PE in patients more than 65 and published after January 1987 and indexed in MEDLINE using keywords as pulmonary embolism, elderly, old, venous thromboembolism (VTE) in the title, abstract or text, were reviewed.

Results

Dyspnea (range 59%–91.5%), tachypnea (46%–74%), tachycardia (29%–76%), and chest pain (26%–57%) represented the most common clinical symptoms and signs. Bed rest was the most frequent risk factor for VTE (15%–67%); deep vein thrombosis was detected in 15%–50% of cases. Sinus tachycardia, right bundle branch block, and ST-T abnormalities were the most frequent ECG findings. Abnormalities of chest X-ray varied (less than 50% in one-half of the studies and more than 70% in the other one-half). Arterial blood gas analysis revealed severe hypoxemia and mild hypocapnia as the main findings. D-Dimer was higher than cut-off in 100% of patients in 75% of studies. Clinical usefulness of D-Dimer measurement decreases with age, although the strategies based on D-Dimer seem to be cost-effective at least until 80 years.

Conclusion

Despite limitations due to pooling data of heterogeneous studies, our review could contribute to the knowledge of the presentation of PE in the elderly with its diagnostic difficulties. A diagnostic strategy based on reviewed data is proposed.

Natural History of Right Ventricular Dysfunction After Acute Pulmonary Embolism

BACKGROUND

Acute pulmonary embolism (PE) associated with right ventricular (RV) dysfunction has an adverse prognosis. We investigated individual parameters of RV dysfunction after acute PE, assessing their correlation with the PE extent and recovery during 6 months.

METHODS

In all, 35 patients (age 63 +/- 18 years) with acute PE were prospectively investigated for 6 months with serial echocardiography, incorporating longitudinal myocardial-velocity and strain imaging. The extent of PE was quantified on day 1 by ventilation/perfusion pulmonary scintigraphy with PE defined as large when there was greater than 30% lung involvement.

RESULTS

PE extent correlated strongly with a number of parameters of RV function, and the strongest univariate correlates were tricuspid annular motion (TAM) (r = -0.65, P < .0001) and the ratio of RV apical to RV basal systolic velocity (r = 0.66, P < .0001). Multivariate analysis identified TAM (P < .0001) and RV basal late-diastolic velocity (P = .01) as independently predicting PE extent, with a combined correlation (R2 = 0.52, P < .0001). A TAM of less than 2.0 cm had sensitivity, specificity, and positive- and negative-predictive values of 75%, 84%, 75%, and 79%, respectively, in predicting large PE. Prospective follow-up identified that RV:left ventricular end-diastolic area ratio returned to normal within 6 weeks, whereas TAM and ratio of RV apical to RV basal systolic velocity normalized after 3 to 6 months.

CONCLUSION

TAM and ratio of RV apical to RV basal systolic velocity are useful indicators of the extent of PE, and provide unique insights into the recovery of RV function after acute PE.

Platelet activation in acute pulmonary embolism

BACKGROUND

Platelet activation is implicated in thrombotic disorders, but has not been described in acute clinical pulmonary embolism (PE).

OBJECTIVES

To investigate the natural history of platelet activation in PE and associated markers of inflammation, thrombosis and cardiac dysfunction.

METHODS

Thirty-five consecutive patients (age 62 +/-17 years) with acute PE were prospectively enrolled and followed for 6 months. Platelet activation was assessed by flow cytometry [measuring expression of platelet P-selectin, conformational activation of glycoprotein IIb/IIIa complex (PAC-1) and formation of platelet-leukocyte complexes] and by plasma soluble P-selectin. Platelet activation, right ventricular (RV) function (assessed as RV ejection area by transthoracic echocardiography), D-dimer and high-sensitivity C-reactive protein (hs-CRP) were measured at presentation and repeated over 6 months follow-up.

RESULTS

Soluble P-selectin (56 +/-19 ng mL(-1), anovaP < 0.0001) and PAC-1 (1.5 +/- 1.8%, anovaP = 0.005) were mildly but significantly increased in patients with acute PE relative to healthy young men (soluble P-selectin 33 +/- 13 ng mL(-1), P < 0.001; PAC-1 binding 0.5 +/- 0.6%, P < 0.01) and age-matched controls (soluble P-selectin 31 +/- 9 ng mL(-1), P < 0.001; PAC-1 binding 0.4 +/-0.4%, P < 0.05). Platelet P-selectin expression and platelet-leukocyte complexes were not increased during acute PE. Echocardiographic RV ejection area correlated inversely with soluble P-selectin (r = -0.47, P = 0.007) and positively with platelet P-selectin (r = 0.49, P = 0.0007), suggesting P-selectin is shed from activated platelets in proportion to the severity of RV dysfunction. Elevated soluble P-selectin, D-dimer and hs-CRP demonstrated a time-dependent return to normal during 6 months follow-up.

CONCLUSION

Platelet activation is evident after acute PE. Platelet activation correlates with the severity of RV dysfunction, and can persist for several months after acute PE.