Risk Stratification Model Predicts Continued Stability in Patients with Pulmonary Embolism
Clinical question: Can right ventricular (RV) dysfunction and troponin levels be used to risk stratify hemodynamically stable patients with acute pulmonary embolism (PE)?
Background: PE can present with varying degrees of clinical severity, necessitating appropriate risk stratification for decision making and management. Observational studies have demonstrated that RV dysfunction and injury provide important prognostic information in patients with acute PE, but this has not been confirmed in large prospective studies.
Study design: Prospective, cohort study.
Setting: Multicenter registry of academic and community hospitals in Italy.
Synopsis: Using the Italian Pulmonary Embolism Registry database of 860 hemodynamically stable patients with PE who underwent troponin measurement and echocardiogram, this study demonstrated that a model including RV dysfunction and injury has an incremental prognostic value for risk stratification of in-hospital death or clinical deterioration. The negative predictive value of negative echocardiography with negative troponin was 100% for in-hospital death and 99% for in-hospital clinical deterioration.
This study was limited by its observational approach; in addition, it did not provide its metrics for defining hemodynamic stability and did not standardize or report treatment strategies for these patients.
The predictive value of this study is impressive and could lead to the identification of patients in whom early discharge or brief hospitalization is appropriate; however, its application could be challenging in clinical environments where timely echocardiography resources are not readily available to a hemodynamically stable patient population.
Bottom line: Negative troponin and absence of RV dysfunction predict clinically stable pulmonary embolism.
Citation: Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest. 2013;144(5):1539-1545.
