A Multimodality Imaging Approach to Defining Risk in Patients With Acute Pulmonary Embolism

Elsevier

Available online 11 May 2023

Journal of the American Society of EchocardiographyAuthor links open overlay panel, , , , , , , AbstractBackground

Morbidity and mortality for acute pulmonary embolism (PE) remain high. Therapies such as catheter directed thrombolysis may improve outcomes but these are generally reserved for higher-risk patients. Imaging may help guide the use of the newer therapies, but current guidelines focus more on clinical factors. Our goal was to create a risk model that incorporated quantitative echocardiographic and computed tomography (CT) measures of right ventricular (RV) size and function, thrombus burden and serum biomarkers of cardiac overload or injury.

Methods

Retrospective study of 150 patients evaluated by a PE response team. Echocardiography was performed within 48 hours of diagnosis. CT measures included RV/LV ratio and thrombus load (Qanadli score). Echocardiography was used to obtain various quantitative measures of right ventricular (RV) function. We compared characteristics of those who met the primary endpoint (7-day mortality and clinical deterioration) to those who did not. Receiver Operating Curve analysis was used to assess the performance of different combinations of clinically relevant features and the association with adverse outcomes.

Results

52% were female, age 62±17, systolic blood pressure 123±25mmHg, heart rate 98±19, troponin 3.2±35 ng/dl and BNP 467± 653). Fourteen (9.3%) were treated with systemic thrombolytics, 27 (18%) underwent catheter-directed thrombolytics, 23 (15%) were intubated or required vasopressors and 14 (9.3%) died. Patients who met the primary endpoint (44%) vs. those who did not (56%), had lower RV S' (6.6 vs. 11.9 cm/s (p<0.001)) and RV free wall strain (-10.9% vs. -13.6% (p=0.005), higher RV/LV ratio on CT and higher serum BNP and troponin levels. ROC analysis demonstrated an AUC of 0.89 for a model that included RV S’, RVFWS and TAPSE/RVSP ratio from echo, thrombus load and RV/LV ratio from CT, and troponin and BNP levels.

Conclusions

A combination of clinical, echo and CT findings that reflect the hemodynamic effects of the embolism identified patients with adverse events related to the acute PE. Optimized scoring systems that focus on reversible abnormalities attributable to the PE may allow more appropriate triaging of intermediate to high-risk patients with PE for early interventional strategy.

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2023 Published by Elsevier Inc. on behalf of the American Society of Echocardiography.

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