engleski

Right ventricular dysfunction assessment in hemodynamically stable pulmonary embolism patients with bedside echocardiography and cardiac biomarkers

Introduction. According to recent studies echocardiography and cardiac biomarkers (BNP, NT- proBNP, cTnT) are useful tools in assessment of RVD and they have a high diagnostic and prognostic value in pulmonary embolism (PE) patients (pts), since almost 50% of them have at least one echocardiography sign of the right heart dysfunction. Echocardiography is a diagnostic method of choice in hemodynamically unstable PE pts without possibility of urgent MSCT pulmonary artery angiography.1 Role of echocardiography in hemodynamically stable PE pts is primarily reserved for additional evaluation of the early mortality risk, since right ventricular dysfunction (RVD) due to PE predicts increased PE- related mortality in normotensive and hypotensive pts.2 Objectives. The aim of present study was to evaluate the prognostic value of bedside echocardiography and cardiac biomarkers in RVD assessment of hemodynamically stable PE pts associated with early adverse outcome. Methods. A single-center prospective study of PE pts was conducted at the medical ICU, Sisters of Mercy University Hospital, Zagreb, Croatia in 2010/2011. Acute PE was confirmed with MSCT angiography. The pts were divided into three severity groups: high- (n=33 ; 31.7%), intermediate- (n=51 ; 49.1%) and low- risk (n=20 ; 19.2%) pts. BNP, NT-proBNP, and cTnT were measured at admission, 6, 12, 24 and 72 hrs following admission. Echocardiography was performed within 24 hrs. The main outcome parameter was in-hospital death. Results. Out of 104 pts, 19 (18.7%) died, none of whom was in the low-risk group (p<0.001). Mean pts age was 68.7±13.4 yrs with female predominance (63.5%). The investigated data confirmed the hypothesis that echocardiography and increased levels of NT- proBNP and cTnT successfully detected PE pts with RVD. This was especially evident in the group of hemdinamically stable pts where echocardiography 61 (85.9%) out of 71 pts ; (P <0.001), NT- proBNP (P=0.006), and cTnT (P=0.037) demonstrated a correlation with RVD. Echocardiography sensitivity in RVD assessment was 98.04% with a specificity of 45%. Effectiveness of echocardiography as a RVD diagnostic tool was assessed with odds ratio [OR: 40.09 (95% CI 4.54- 1826.84)]. Right ventricular dilatation, free wall motion abnormalities, tricuspid regurgitation, pulmonary hypertension and paradoxical movements of the interventricular septum were correlated with RVD (P <0.001 for all). The Friedman test was used to determine the dynamics of cardiac biomarkers release. The data showed a significant increase in cTnT and NT- proBNP release between initial and first control sampling, in both the high- and intermediate-risk PE pts groups (P<0.001). NT- proBNP levels >500pg/mL might detect pts with persistent RVD 48 hrs following admission and therefore could provide additional information regarding risk stratification. Initial BNP correlated with the PE outcome, concentrations ≥526 pg/mL showed a negative predictive value of 100%. Conclusion. Bedside echocardiography and increased levels of cTnT and NT-proBNP successfully detected hemodinamically stable PE pts with RVD, while initially increased levels of BNP detected pts with a higher risk of death. Serial sampling of NT-proBNP, up to 48 hrs, might be useful in detecting pts with persistent RVD, and therefore could provide additional information in further risk stratification. References: 1. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008 ; 29:2276–2315. 2. Sanchez O, Trinquart L, Colombet I, Durieux P, Huisman MV, Chatellier G, Meyer G. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J. 2008 ; 29(12):1569-77. Epub 2008 May 21.

pulmonary embolism ; right ventricle dysfunction ; outcome

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