Dudzinski David M, Hariharan Praveen, Parry Blair A, Chang Yuchiao, Kabrhel Christopher
Center for Vascular Emergencies, Massachusetts General Hospital, Boston, MA.
Cardiology Division, Massachusetts General Hospital, Boston, MA.
Acad Emerg Med. 2017 Mar;24(3):337-343. doi: 10.1111/acem.13108.
Right ventricular strain (RVS) identifies patients at risk of hemodynamic deterioration from pulmonary embolism (PE). Our hypothesis was that chest computed tomography (CT) can provide information about RVS analogous to transthoracic echocardiography (TTE) and that RVS on CT is associated with adverse outcomes after PE.
Consecutive emergency department patients with acute PE were prospectively enrolled and clinical, biomarker, and imaging data were recorded. CTs were overread by two radiologists. We compared diagnoses of RVS on CT (defined as right ventricle:left ventricle ratio ≥ 0.9 or interventricular septal bowing) to echocardiography (defined as right ventricular hypokinesis, right ventricular dilatation, or interventricular septal bowing). We calculated the test characteristics (with 95% confidence interval) of CT and TTE for a composite outcome of severe clinical deterioration, thrombolysis/thrombectomy, or death within 5 days.
A total of 298 patients were enrolled; 274 had CT and 118 had formal TTE. Of the 104 patients who had both CT and TTE, the mean (±SD) age was 58 (±17) years; 50 (48%) were female and 88 (85%) were Caucasian. Forty-two (40%) had RVS by TTE and 75 (72%) had RVS by CT. CT and TTE agreed on the presence or absence of RVS in 61 (59%) cases (κ = 0.24). Using TTE as criterion standard, the test characteristics of CT for RVS were as follows: sensitivity = 88%, specificity = 39%, positive predictive value = 49%, and negative predictive value = 83%. Fourteen (13%) patients experienced severe clinical deterioration or required hospital-based intervention within 5 days. This occurred in 30% of patients with RVS on both TTE and CT, 20% of patients with RVS on TTE alone, 3% of patients with RVS on CT alone, and 4% of patients without RVS on either modality.
In acute PE, CT is highly sensitive but only moderately specific for RVS compared to TTE. RVS on both CT and TTE predicts more events than either modality alone. TTE confers additional positive prognostic value compared to CT in predicting post-PE clinical deterioration.
右心室应变（RVS）可识别出有因肺栓塞（PE）导致血流动力学恶化风险的患者。我们的假设是胸部计算机断层扫描（CT）能够提供与经胸超声心动图（TTE）类似的有关RVS的信息，且CT上的RVS与PE后的不良结局相关。
前瞻性纳入急诊科连续的急性PE患者，并记录临床、生物标志物和影像学数据。两名放射科医生对CT进行复核。我们将CT上RVS的诊断（定义为右心室：左心室比率≥0.9或室间隔弯曲）与超声心动图（定义为右心室运动减弱、右心室扩张或室间隔弯曲）进行比较。我们计算了CT和TTE对于严重临床恶化、溶栓/血栓切除术或5天内死亡这一复合结局的检验特征（95%置信区间）。
共纳入298例患者；274例进行了CT检查，118例进行了正式的TTE检查。在104例同时进行了CT和TTE检查的患者中，平均（±标准差）年龄为58（±17）岁；50例（48%）为女性，88例（85%）为白种人。42例（40%）通过TTE检查发现有RVS，75例（72%）通过CT检查发现有RVS。CT和TTE在61例（59%）病例中对RVS的存在与否判断一致（κ = 0.24）。以TTE作为标准参照，CT对于RVS的检验特征如下：敏感性 = 88%，特异性 = 39%，阳性预测值 = 49%，阴性预测值 = 83%。14例（13%）患者在5天内出现严重临床恶化或需要住院干预。这在TTE和CT检查均显示有RVS的患者中占30%，仅TTE检查显示有RVS的患者中占20%，仅CT检查显示有RVS的患者中占3%，两种检查均未显示有RVS的患者中占4%。
在急性PE中，与TTE相比，CT对RVS高度敏感但特异性一般。CT和TTE检查均显示有RVS比单独任何一种检查预测的事件更多。在预测PE后临床恶化方面，与CT相比，TTE具有额外的阳性预后价值。
