Implications of elevated cardiac troponin in patients presenting with acute pulmonary embolism: an observational study

Diagnostic and Prognostic Value of RV Strain Defined as RV/LV Ratio on Chest CT in Acute Pulmonary Embolism: A Systematic Review

BACKGROUND

Pulmonary embolism (PE) is a common cause of acute RV enlargement (often described as RV strain or RV-S), with significant associated mortality and morbidity. Chest CT pulmonary angiography is a widely available diagnostic modality to rule out PE and assess for RV-S, if positive for PE. Frequently, RV-S is assessed by measuring the right ventricular (RV) to left ventricular (LV) ratio (RV/LV ratio); however, there is no standardized technique for measuring CT RV/LV ratio, and the prognostic value of this marker is not well-defined.

METHODS

PubMed and EMBASE databases were searched from inception to December 2023. A total of 35 studies were eligible for data collection based on relevance, completeness, and quality of data.

RESULTS

The most common clinically effective cutoffs of the RV/LV ratio used were 0.9 and 1.0, and the most common methodology involved measuring RV and LV diameters within the same axial slice on both 2D (axial) and reconstructed 4-Chamber (4-Ch) views. Although 4-Ch and axial views had different RV/LV ratio predictability regarding specific outcomes such as 30-day death, there was no significant overall difference in the prognostic value across the different cutoffs used.

CONCLUSIONS

Our study demonstrates a lack of definite standardization in measuring CT RV/LV ratio in acute PE. Based on our review, we propose an RV strain defined as CT RV/LV ratio >1.0 measured on a single axial CT slice as an easily measurable and reliable marker of RV dysfunction in acute PE, with associated significant prognostic value in predicting adverse outcomes.

The Prognostic Value of Inflammatory Indices in Acute Pulmonary Embolism

Background: Acute pulmonary embolism (PE) is a condition with increased morbidity and mortality. It is important to identify patients with high mortality risk. Inflammation and thrombosis are interconnected in the pathophysiology of PE. The aim of the study was to investigate the prognostic value of multiple blood cellular indices such as neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte platelet ratio (NLPR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI) and aggregate index of systemic inflammation (AISI) in acute PE. Methods: A total of 157 patients with acute PE confirmed by chest computed tomographic angiography (CTPA) were enrolled. These patients were divided into two categories according to the simplified pulmonary embolism severity index (sPESI): high risk and low risk. Results: Univariate logistic regression analysis showed that right ventricle dysfunction, NLR, SII and SIRI were significantly associated with high risk of acute PE. NLR of 4.32 was associated with high-risk PE with a sensitivity of 57.4% and specificity of 65.7% (AUC = 0.635). SII of 1086.55 was associated with high-risk PE with a sensitivity of 55.7% and specificity of 71.4% (AUC = 0.614). SIRI of 2.87 was associated with high-risk PE with a sensitivity of 59% and specificity of 62.9% (AUC = 0.624). Multivariate logistic regression analysis demonstrated that right ventricle dysfunction, NLR, PLR and NLPR are independent predictors of high-risk acute PE. Secondly, NLR, NLPR, SII and SIRI were significantly correlated with in-hospital mortality of acute PE. Based on receiver-operating characteristic (ROC) curve values of 7.66 for NLR (AUC 0.911, sensitivity of 85.7% and sensibility of 83%), 0.02 for NLPR (AUC 0.871, sensitivity of 85.7% and sensibility of 70%), 1542.71 for SII (AUC 0.782, sensitivity of 71.4% and sensibility of 72%) and 5.72 for SIRI (AUC 0.788, sensitivity of 71.4% and sensibility of 73%) could predict in-hospital mortality. Conclusions: The blood cellular indices (NLR, NLPR, SII and SIRI) are associated with high-risk acute PE and in-hospital mortality. Right ventricular dysfunction, NLR and NLPR are independent predictors for high-risk acute PE.

Optimizing Use of High-Sensitivity Troponin for Risk-Stratification of Acute Pulmonary Embolism

BACKGROUND

 High-sensitivity troponin T (HS-TnT) may improve risk-stratification in hemodynamically stable acute pulmonary embolism (PE), but an optimal strategy for combining this biomarker with clinical risk-stratification tools has not been determined.

STUDY HYPOTHESIS

 We hypothesized that different HS-TnT cutoff values may be optimal for identifying (1) low-risk patients who may be eligible for outpatient management and (2) patients at increased risk of clinical deterioration who might benefit from advanced PE therapies.

METHODS

 Retrospective analysis of hemodynamically stable patients in the University of Michigan acute ED-PE registry with available HS-TnT values. Primary and secondary outcomes were 30-day mortality and need for intensive care unit-level care. Receiver operating characteristic curves were used to determine optimal HS-TnT cutoffs in the entire cohort, and for those at higher risk based on the simplified Pulmonary Embolism Severity Index (PESI) or imaging findings.

RESULTS

 The optimal HS-TnT cutoff in the full cohort, 12 pg/mL, was significantly associated with 30-day mortality (odds ratio [OR]: 3.94, 95% confidence interval [CI]: 1.48-10.50) and remained a significant predictor after adjusting for the simplified PESI (sPESI) score and serum creatinine (adjusted OR: 3.05, 95% CI: 1.11-8.38). A HS-TnT cutoff of 87 pg/mL was associated with 30-day mortality (OR: 5.01, 95% CI: 2.08-12.06) in patients with sPESI ≥1 or right ventricular dysfunction.

CONCLUSION

 In this retrospective, single-center study of acute PE patients, we identified distinct optimal HS-TnT values for different clinical uses-a lower cutoff, which identified low-risk patients even in the absence of other risk-stratification methods, and a higher cutoff, which was strongly associated with adverse outcomes in patients at increased risk.

The Role of Troponin in the Diagnosis and Treatment of Acute Pulmonary Embolism: Mechanisms of Elevation, Prognostic Evaluation, and Clinical Decision-Making

Acute pulmonary embolism (APE) is a cardiovascular disease with severe consequences, wherein cardiac troponin (Tn) plays a pivotal role in diagnosis and treatment. This article reviews the various roles of Tn in managing APE. It looks at how Tn levels increase, their importance in predicting outcomes, and their use in making clinical decisions. Studies indicate that an elevation in Tn is primarily associated with right ventricular overload, ischemia, and necrosis, changes that directly reflect the extent of right ventricular dysfunction and myocardial injury. Elevated levels of Tn are significantly correlated with both short-term and long-term mortality risks in patients with APE, serving as crucial indicators for prognostic assessment and guiding therapeutic strategies. International guidelines recommend integrating Tn testing with clinical scoring and echocardiography to optimize treatment decisions in patients with APE. Despite the significant value of Tn determination in the management of APE, further research is needed to standardize its application. This paper emphasizes future research directions, including exploring the application of Tn in different patient subgroups with APE and its potential combined use with other biomarkers.

The correlation between the CT angiographic pulmonary artery obstructive index and clinical data in patients with acute pulmonary thromboembolism

PURPOSE

The potentially fatal consequences of pulmonary embolism emphasize the need for more effective diagnostic methods. The Qanadli obstruction index has been described as a convenient tool for risk stratification to determine and quantify the degree of obstruction. This study aimed to assess the correlations between the Qanadli index with clinical and paraclinical findings (D-dimer, troponin, and echocardiographic findings) in patients with pulmonary embolism.

MATERIALS AND METHODS

A total of 102 patients with pulmonary embolism underwent echocardiography and CT pulmonary angiography at a single tertiary referral center between 2019 and 2020. The clinical and paraclinical findings, pulmonary arterial obstruction index, atrial measurements, right and left ventricle size and function, tricuspid annular plane systolic excursion, pulmonary artery pressure, and pulmonary hypertension (PH) were analyzed. Vital signs were recorded and assessed. The Qanadli index score was measured, and graded risk stratification was measured based on the quantified index score.

RESULTS

The total mean Qanadli index was 28.75 ± 23.75, and there was no significant relationship between the Qanadli index and gender. Patients' most common clinical findings were exertional dyspnea (84.3%; n = 86) and chest pain (71.7%; n = 73). There were significant correlations between the Qanadli index and pulse rate (PR), troponin, D-dimer levels, and PH. Four patients died during the study, including one from a cardiac condition and three with non-cardiac conditions.

CONCLUSIONS

It is possible to determine the severity, prognosis, and appropriate treatment by the Qanadli index based on strong correlations with PR, troponin, D-dimer levels, and PH.

Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis

AIMS

Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone.

METHODS AND RESULTS

Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74).

CONCLUSION

RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay.

Prognostic Value of D-Dimer in Younger Patients with Pulmonary Embolism

In patients with pulmonary embolism (PE), the D-Dimer assay is commonly utilized as part of the diagnostic workup, but data on D-Dimer for early risk stratification and short-term mortality prediction are limited. The purpose of this study was to determine D-Dimer levels as a predictive biomarker of PE outcomes in younger (<50 years of age) compared to older patients. We conducted retrospective analysis for 930 patients diagnosed with PE between 2015 and 2019 as part of the Serbian University Multicenter Pulmonary Embolism Registry (SUPER).All patients had D-Dimer levels measured within 24 hours of hospital admission. The primary outcome was mortality at 30 days or during hospitalization. Patients were categorized into two groups based on age (≤ 50 and >50 years of age). Younger patients constituted 20.5% of the study cohort. Regarding all-cause mortality, 5.2% (10/191)of patients died in group under the 50 years of age; the short-term all-causemortality was 12.4% (92/739) in older group.We have found that there was significant difference in plasma D-Dimer level between patients ≤ 50 years of age and older group (>50), p= 0.006.D-Dimer plasma level had good predictive value for the primary outcome in younger patients (c-statistics 0.710; 95% CI, 0.640-0.773; p<0.031). The optimal cutoff level for D-Dimer to predict PE-cause death in patients aged > 50 years was found to be 8.8 mg/l FEU(c-statistics 0,580; 95% CI 0.544-0.616; p=0.049). In younger PE patients, D-Dimer levels have good prognostic performance for 30-day all-cause mortalityand concentrations above 6.3 mg/l FEU are associated with increased risk of death. D-Dimer in patients aged over 50 years does not have predictive ability for all-caused short-term mortality. The relationship between D-Dimer and age in patients with PE may need further evaluation.