Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism

Prognostic significance of diastolic wall strain as a predictor of remodeling and poor outcomes in heart failure and pulmonary embolism: A systematic review

BACKGROUND

Diastolic wall strain (DWS), also referred to as right ventricular (RV) dysfunction, is a significant predictor of pulmonary embolism (PE) and heart failure (HF). Rooted in linear elastic theory, DWS reflects decreased wall thinning during diastole, indicating reduced left ventricular (LV) compliance and increased diastolic stiffness. Elevated diastolic stiffness is associated with worse outcomes, particularly in PE and HF with preserved ejection fraction (HFpEF). This study systematically reviews the prognostic significance of DWS and its impact on PE and HF.

METHODS

A systematic search of scientific literature published between 2014 and 2024 was conducted using PubMed and Cochrane Reviews. Keywords such as "diastolic wall strain," "right ventricular dysfunction," and "pulmonary embolism" were employed to identify relevant studies. Seven articles meeting the inclusion criteria were selected and analyzed to synthesize insights into DWS and its role in risk stratification and prognosis for PE and HF patients.

RESULTS

The findings suggest that elevated DWS values are correlated with increased short- and long-term mortality in PE patients and a higher likelihood of early complications in both PE and HF. In cases where HF is present alongside elevated DWS, the risk of significant bleeding is heightened. DWS emerged as a reliable tool for PE risk stratification and predicting adverse outcomes in HF patients.

CONCLUSION

DWS is an essential prognostic marker for PE and HF, independently predicting major adverse cardiac events (MACE). Its straightforward assessment can improve risk stratification and guide clinical management in individuals at risk for cardiac failure.

A Novel Tool for Predicting an Abnormal Echocardiogram in Patients with Pulmonary Embolism: The PEACE Score

BACKGROUND

Transthoracic echocardiography (TTE) is an essential tool for risk-stratifying patients with pulmonary embolism (PE), but its availability is limited, often requiring hospitalization. Minimal research exists evaluating clinical and laboratory criteria to predict lack of abnormal TTE findings.

OBJECTIVE

We aimed to identify predictors associated with abnormal TTE results in patients with PE to potentially identify those safe for early discharge.

METHODS

In this retrospective study, we analyzed an existing database of patients with venous thromboembolism (VTE) at two academic emergency departments, including adult patients with confirmed PE who underwent TTE. The primary goal was to develop and validate a score predicting abnormal TTE, defined as presence of one of the following: right ventricle (RV) dilatation or hypokinesis, septal flattening, right heart thrombus in transit, or ejection fraction < 50%. Variables were demographic characteristics, symptoms, computed tomography (CT) RV strain, troponin T, and N-terminal prohormone of brain natriuretic peptide (NTproBNP). Stepwise logistic regression was used to identify variables independently associated with abnormal TTE. Model discrimination was evaluated using area under the curve (AUC) of the receiver operating characteristic curve. A clinical prediction rule was developed.

RESULTS

530 of 2235 patients were included; 56% (297 of 530) had an abnormal TTE. The following six variables were independently associated with abnormal TTE: dyspnea, dizziness, troponin T ≥ 0.1 ng/mL, NTproBNP > 900 pg/mL, CT RV strain, and nonsubsegmental PE. A clinical prediction rule using these six criteria yielded scores between 0 and 7, performing well with AUC of 0.80 (95% CI 0.79-0.80). A score of 1 was 99.7% sensitive in identifying no abnormality. A score ≥ 5 was 98% specific for an abnormality.

CONCLUSIONS

The PEACE (Pulmonary Embolism and Abnormal Cardiac Echocardiogram) criteria, composed of six variables, is highly effective in predicting abnormal TTE in patients with PE, potentially identifying who is safe for early discharge from the hospital.

Left ventricular systolic dysfunction during acute pulmonary embolism

BACKGROUND

Heart failure increases the risk of death in acute pulmonary embolism (PE). The role of the left ventricle (LV) in acute PE is not well defined.

OBJECTIVE

To identify the prevalence of LV systolic dysfunction, morphology, and prognosis of the LV during an acute PE.

METHODS

Retrospective study (26-months) of patients diagnosed with an acute PE presenting with LV systolic dysfunction at the University of Maryland.

RESULTS

Among 769 acute PE patients, 78 (10.5 %) had LV systolic dysfunction and 42 (53.8 %) had history of cardiac disease. Patients without history of cardiac disease were younger (mean age [SD] 54.9 [16.8] vs. 62.6 [16.6]; p = 0.04), had a higher BMI (31.2 [12.2] vs. 29.2 [7.7]; p = 0.005), and less hypertension (20 [34.5 %] vs. 38 [65.5 %]; p = 0.0005). A massive PE was most common in patients without history of cardiac disease (8[22.2 %] vs. 2[4.7 %], p = 0.02). There was no difference in clot burden, but right ventricular strain was more frequently seen in patients without history cardiac disease in the initial CT (p = 0.001). The median troponin and lactate were similar in both groups. In 41 patients with follow-up echocardiograms, improvement in LVEF% was observed in patients without cardiac history (median Δ LVEF% [IQR]; 20 [6.2-25.0]). While patients with cardiac disease did not demonstrate similar changes (median Δ LVEF% [IQR]; 0 [-5-17.5]; p = 0.01). In hospital mortality was 12.8 % with no difference between both groups (p = 0.17).

CONCLUSION

Pulmonary embolism can be associated with LV systolic dysfunction, even in patients without history of cardiac disease.

Clinical outcomes and echocardiographic characteristics between African American and Caucasian patients with acute pulmonary embolism

Background

Despite socioeconomic disparities, no association between clinical presentation and poor outcomes explains a higher mortality in African Americans with pulmonary embolism (PE). The objective is to identify the co-morbidities and echocardiographic characteristics associated with increased mortality in African American patients.

Methods

This is a cross-sectional study of Caucasian or African American patients with PE diagnosed between October 2015 and December 2017 at University of Maryland Medical Center. The outcomes were in-hospital death, length of stay, and bleeding.

Results

There were 303 African Americans and 343 Caucasians. Caucasians were older ( p = 0.007), males ( p = 0.01) with history of coronary artery revascularization (CABG ( p = 0.001), coronary stents ( p = 0.001)), trauma ( p = 0.007), and/or recent surgeries ( p = 0.0001). African Americans exhibited higher rates of diabetes ( p = 0.01), chronic kidney disease ( p = 0.0005), and smoking ( p = 0.04). Severity of PE was similar between groups and there was no difference in clot burden size. African Americans had more right ventricular strain on Computer Tomography ( p = 0.001) and echocardiogram ( p = 0.004); also, underfilled left ventricles ( p = 0.02) and higher right ventricular systolic pressures ( p = 0.001). There was no difference in hospital mortality (7.1% vs. 7.9%, p = 0.71), length of stay (13.1 ± 16.7 vs 12.8 ± 14.9, p = 0.80) and bleeding (9.0% vs.8.3%. p = 0.72). Mortality was higher in African Americans who received advanced therapies (3.8% vs. 18.8%, p = 0.02). The risk of death increased with age (OR 1.04; 95%CI 1.020–1.073) and with advanced therapies (OR 2.43; 95%CI 1.029–5.769).

Conclusions

Differences in co-morbidities, radiologic findings, and echocardiographic characteristics that may contribute to higher mortality in African American patients, specifically those receiving advanced therapies.

Acute Saddle Embolus With Thrombus in Transit: A Case Report and Review of the Literature

Pulmonary embolism is a life-threatening medical emergency associated with right ventricular failure. Rarely, it impacts the left ventricle to the point of compromising the left ventricular (LV) ejection fraction. We present a case of a 73-year-old African American male with a medical history pertinent for intravascular large B-cell lymphoma who developed an acute saddle embolus with a “clot-in-transit” and profound LV systolic dysfunction. Our report illustrates how an acute saddle embolus may be associated with LV systolic dysfunction via the “reverse Bernheim effect.” Additionally, the report highlights the significance of a “clot-in-transit” and LV systolic dysfunction, as they both directly correlate with increased risk of mortality.

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.