Internal Medicine Department, Hospital de São Francisco Xavier, Portugal.
Cardiology Department, Hospital de Santa Cruz, Portugal.
Eur Heart J Acute Cardiovasc Care. 2020 Jun;9(4):279-285. doi: 10.1177/2048872619846506. Epub 2019 Apr 24.
Patients with acute pulmonary embolism are at intermediate-high risk in the presence of imaging signs of right ventricular dysfunction plus one or more elevated cardiac biomarker. We hypothesised that intermediate-high risk patients with two elevated cardiac biomarkers and imaging signs of right ventricular dysfunction have a worse prognosis than those with one cardiac biomarker and imaging signs of right ventricular dysfunction.
We analysed the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction in 525 patients with intermediate risk pulmonary embolism (intermediate-high risk = 237) presenting at the emergency department in two centres. Studied endpoints were composites of all-cause mortality and/or rescue thrombolysis at 30 days (primary endpoint; =58) and pulmonary embolism-related mortality and/or rescue thrombolysis at 30 days (secondary endpoint; =40).
Patients who experienced the primary endpoint showed a higher proportion of elevated troponin (47% vs. 76%, <0.001), elevated N-terminal pro-brain natriuretic peptide (67% vs. 93%, <0.001) and imaging signs of right ventricular dysfunction (47% vs. 80%, <0.001). Multivariate analysis revealed N-terminal pro-brain natriuretic peptide (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.3-10.3; =0.015) and imaging signs of right ventricular dysfunction (HR 2.8, 95% CI 1.5-5.2; =0.001) as independent predictors of events. In the intermediate-high risk group, patients with two cardiac biomarkers performed worse than those with one cardiac biomarker (HR 3.3, 95% CI 1.8-6.2; =0.003).
Risk stratification in normotensive pulmonary embolism should consider the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction, especially in the intermediate-high risk subgroup.
在存在右心室功能障碍影像学征象和一种或多种升高的心脏生物标志物的情况下，急性肺栓塞患者处于中高危状态。我们假设，两种心脏生物标志物升高且存在右心室功能障碍影像学征象的中高危患者比一种心脏生物标志物升高且存在右心室功能障碍影像学征象的患者预后更差。
我们分析了两个中心急诊科就诊的 525 例中危肺栓塞（中高危=237 例）患者的心脏生物标志物和右心室功能障碍影像学征象的累积出现情况。研究终点为 30 天内全因死亡率和/或补救性溶栓（主要终点；=58 例）以及 30 天内肺栓塞相关死亡率和/或补救性溶栓（次要终点；=40 例）的复合事件。
发生主要终点的患者出现升高的肌钙蛋白（47%比 76%，<0.001）、升高的 N 末端脑利钠肽前体（67%比 93%，<0.001）和右心室功能障碍影像学征象（47%比 80%，<0.001）的比例更高。多变量分析显示，N 末端脑利钠肽前体（危险比（HR）3.6，95%置信区间（CI）1.3-10.3；=0.015）和右心室功能障碍影像学征象（HR 2.8，95%CI 1.5-5.2；=0.001）是事件的独立预测因素。在中高危组中，两种心脏生物标志物阳性的患者比一种心脏生物标志物阳性的患者预后更差（HR 3.3，95%CI 1.8-6.2；=0.003）。
在血压正常的肺栓塞中进行风险分层时，应考虑心脏生物标志物和右心室功能障碍影像学征象的累积存在，尤其是在中高危亚组中。
