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Biomarker-based strategy for screening right ventricular dysfunction in patients with non-massive pulmonary embolism

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Abstract

Objective

To evaluate the usefulness of B-type natriuretic peptide and troponin I measurements in predicting right ventricular dysfunction (RVD) in non-massive pulmonary embolism.

Design

Prospective observational study.

Setting

University-affiliated emergency unit, cardiology and pneumology departments.

Patients

Sixty-seven patients admitted because of acute pulmonary embolism, without shock on admission, completed the study.

Interventions

Blood samples and echocardiography were obtained on admission for subsequent and independent assessment of B-type natriuretic peptide (BNP) and troponin I levels as well as RVD.

Measurements and results

Echocardiographic RVD was diagnosed in 36 patients and was severe in 13 on admission. BNP and troponin I levels were higher in patients with RVD than in those with no RVD [62 (27–105) vs. 431 (289–556) pg/ml for BNP, p < 0.001; 0.01 (0–0.09) vs. 0.16 (0.03–0.32) μg/l for troponin I, p = 0.005]. The area under the receiving operating characteristic curve (AUC) for diagnosing RVD was 0.93 for BNP and 0.72 for troponin I. The troponin I level increased further when RVD was severe, compared with moderate, and the AUC was 0.91 for identifying severe RVD. Diagnoses of RVD and severe RVD were ruled out by BNP ≤ 100 pg/ml (30% of patients) and troponin I 0.10 μg/l (58% of patients), respectively. In-hospital death or circulatory failure occurred in nine patients; all had echographic RVD and level of BNP > 100 pg/ml and troponin I > 0.10 μg/l.

Conclusion

In hemodynamically stable pulmonary embolism, BNP/troponin I measurement is helpful on admission, especially for ruling out RVD, i. e. patients with in-hospital high-risk.

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Abbreviations

RVD:

right ventricular dysfunction

BNP:

B-type natriuretic peptide

ECG:

electrocardiographic

AUC:

area under the receiving operating characteristic curve

References

  1. Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, Conti A, Agnelli G, Berni G (2000) Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 101:2817–2822

    PubMed  CAS  Google Scholar 

  2. Goldhaber SZ, Visani L, De Rosa M (1999) Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 353:1386–1389

    Article  PubMed  CAS  Google Scholar 

  3. Kasper W, Konstantinides S, Geibel A, Tiede N, Krause K, Just H (1997) Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 77:346–349

    PubMed  CAS  Google Scholar 

  4. Goldhaber SZ, Elliott CG (2003) Acute pulmonary embolism: part I: epidemiology, pathophysiology, and diagnosis. Circulation 108:2726–2729

    Article  PubMed  Google Scholar 

  5. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W (2002) Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 347:1143–1150

    Article  PubMed  CAS  Google Scholar 

  6. Goldhaber SZ (2002) Echocardiography in the management of pulmonary embolism. Ann Intern Med 136:691–700

    PubMed  Google Scholar 

  7. Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F (2002) Echo-Doppler demonstration of acute cor pulmonale at the bedside in the medical intensive care unit. Am J Respir Crit Care Med 166:1310–1319

    Article  PubMed  Google Scholar 

  8. Jardin F, Dubourg O, Bourdarias JP (1997) Echocardiographic pattern of acute cor pulmonale. Chest 111:209–217

    PubMed  CAS  Google Scholar 

  9. Jaffe AS, Babuin L, Apple FS (2006) Biomarkers in acute cardiac disease: the present and the future. J Am Coll Cardiol 48:1–11

    Article  PubMed  CAS  Google Scholar 

  10. Jason P, Keang LT, Hoe LK (2005) B-type natriuretic peptide: issues for the intensivist and pulmonologist. Crit Care Med 9:2094–2103

    Article  Google Scholar 

  11. The PIOPED Investigators (1990) Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 263:2753–2759

    Article  Google Scholar 

  12. Schoepf UJ, Goldhaber SZ, Costello P (2004) Spiral computed tomography for acute pulmonary embolism. Circulation 109:2160–2167

    Article  PubMed  Google Scholar 

  13. Miller GA, Sutton GC, Kerr IH, Gibson RV, Honey M (1971) Comparison of streptokinase and heparin in treatment of isolated acute massive pulmonary embolism. Br Heart J 33:616

    PubMed  CAS  Google Scholar 

  14. Ribeiro A, Juhlin-Dannfelt A, Brodin LA, Holmgren A, Jorfeldt L (1998) Pulmonary embolism: relation between the degree of right ventricle overload and the extent of perfusion defects. Am Heart J 135:868–874

    Article  PubMed  CAS  Google Scholar 

  15. Mansencal N, Joseph T, Vieillard-Baron A, Langlois S, El Hajjam M, Qanadli SD, Lacombe P, Jardin F, Dubourg O (2005) Diagnosis of right ventricular dysfunction in acute pulmonary embolism using helical computed tomography. Am J Cardiol 95:1260–1263

    Article  PubMed  Google Scholar 

  16. Kostrubiec M, Pruszczyk P, Bochowicz A, Pacho R, Szulc M, Kaczynska A, Styczynski G, Kuch-Wocial A, Abramczyk P, Bartoszewicz Z, Berent H, Kuczynska K (2005) Biomarker-based risk assessment model in acute pulmonary embolism. Eur Heart J 26:2166–2172

    Article  PubMed  CAS  Google Scholar 

  17. Phua J, Lim TK, Lee KH (2005) B-type natriuretic peptide: issues for the intensivist and pulmonologist. Crit Care Med 33:2094–2013

    Article  PubMed  Google Scholar 

  18. Vieillard-Baron A, Page B, Augarde R, Prin S, Qanadli S, Beauchet A, Dubourg O, Jardin F (2001) Acute cor pulmonale in massive pulmonary embolism: incidence, echocardiographic pattern, clinical implications and recovery rate. Intensive Care Med 27:1481–1486

    Article  PubMed  CAS  Google Scholar 

  19. Nagaya N, Nishikimi T, Okano Y, Uematsu M, Satoh T, Kyotani S, Kuribayashi S, Hamada S, Kakishita M, Nakanishi N, Takamiya M, Kunieda T, Matsuo H, Kangawa K (1998) Plasma brain natriuretic peptide levels increase in proportion to the extent of right ventricular dysfunction in pulmonary hypertension. J Am Coll Cardiol 31:202–208

    Article  PubMed  CAS  Google Scholar 

  20. Kruger S, Graf J, Merx MW, Koch KC, Kunz D, Hanrath P, Janssens U (2004) Brain natriuretic peptide predicts right heart failure in patients with acute pulmonary embolism. Am Heart J 147:60–65

    Article  PubMed  CAS  Google Scholar 

  21. Pruszczyk P, Kostrubiec M, Bochowicz A, Styczynski G, Szulc M, Kurzyna M, Fijalkowska A, Kuch-Wocial A, Chlewicka I, Torbicki A (2003) N-terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism. Eur Respir J 22:649–653

    Article  PubMed  CAS  Google Scholar 

  22. Tulevski II, Hirsch A, Sanson BJ, Romkes H, van der Wall EE, van Veldhuisen DJ, Buller HR, Mulder BJ (2001) Increased brain natriuretic peptide as a marker for right ventricular dysfunction in acute pulmonary embolism. Thromb Haemost 86:1193–1196

    PubMed  CAS  Google Scholar 

  23. Missov E, Calzolari C, Pau B (1997) Circulating cardiac troponin I in severe congestive heart failure. Circulation 96:2953–2958

    PubMed  CAS  Google Scholar 

  24. Logeart D, Beyne P, Cusson C, Tokmakova M, Leban M, Guiti C, Bourgoin P, Cohen Solal A (2001) Evidence of cardiac myolysis in severe nonischemic heart failure and the potential role of increased wall strain. Am Heart J 141:247–253

    Article  PubMed  CAS  Google Scholar 

  25. Kucher N, Printzen G, Goldhaber SZ (2003) Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation 107:2545–2547

    Article  PubMed  CAS  Google Scholar 

  26. ten Wolde M, Tulevski II, Mulder JW, Sohne M, Boomsma F, Mulder BJ, Buller HR (2003) Brain natriuretic peptide as a predictor of adverse outcome in patients with pulmonary embolism. Circulation 107:2082–2084

    Article  PubMed  CAS  Google Scholar 

  27. Pieralli F, Olivotto I, Vanni S, Conti A, Camaiti A, Targioni G, Grifoni S, Berni G (2006) Usefulness of bedside testing for brain natriuretic peptide to identify right ventricular dysfunction and outcome in normotensive patients with acute pulmonary embolism. Am J Cardiol 97:1386–1390

    Article  PubMed  CAS  Google Scholar 

  28. Kucher N, Printzen G, Doernhoefer T, Windecker S, Meier B, Hess PM (2003) Low pro-brain natriuretic peptide levels predict benign clinical outcome in acute pulmonary embolism. Circulation 107:1576–1578

    Article  PubMed  Google Scholar 

  29. Binder L, Pieske B, Olschewski M, Geibel A, Klostermann B, Reiner C, Konstantinides S (2005) N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 112:1573–1579

    Article  PubMed  CAS  Google Scholar 

  30. Logeart D, Saudubray C, Beyne P, Thabut G, Ennezat PV, Chavelas C, Zanker C, Bouvier E, Cohen, Solal A (2002) Comparative value of Doppler echocardiography and B-type natriuretic peptide assay in the etiologic diagnosis of acute dyspnea. J Am Coll Cardiol 40:1794–1800

    Article  PubMed  Google Scholar 

  31. Goldhaber SZ (2001) Thrombolysis in pulmonary embolism: a large-scale clinical trial is overdue. Circulation 104:2876–2878

    PubMed  CAS  Google Scholar 

  32. Goldhaber SZ (2005) Thrombolytic therapy for patients with pulmonary embolism who are hemodynamically stable but have right ventricular dysfunction: pro. Arch Intern Med 165:2197–2199; discussion 2204–2205

    Article  PubMed  Google Scholar 

  33. Thabut G, Logeart D (2005) Thrombolysis for pulmonary embolism in patients with right ventricular dysfunction: con. Arch Intern Med 165:2200–2203; discussion 2204–2205

    Article  PubMed  Google Scholar 

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Correspondence to Damien Logeart.

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Logeart, D., Lecuyer, L., Thabut, G. et al. Biomarker-based strategy for screening right ventricular dysfunction in patients with non-massive pulmonary embolism. Intensive Care Med 33, 286–292 (2007). https://doi.org/10.1007/s00134-006-0482-1

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  • DOI: https://doi.org/10.1007/s00134-006-0482-1

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