Cardiac troponin testing and the simplified Pulmonary Embolism Severity Index

Summary

A low simplified Pulmonary Embolism Severity Index (sPESI), defined as age ≤80 years and absence of systemic hypotension, tachycardia, hypoxia, cancer, heart failure, and lung disease, identifies low-risk patients with acute pulmonary embolism (PE). It is unknown whether cardiac troponin testing improves the prediction of clinical outcomes if the sPESI is not low. In the prospective Swiss Venous Thromboembolism Registry, 369 patients with acute PE and a troponin test (conventional troponin T or I, highly sensitive troponin T) were enrolled from 18 hospitals. A positive test result was defined as a troponin level above the manufacturers assay threshold. Among the 106 (29%) patients with low sPESI, the rate of mortality or PE recurrence at 30 days was 1.0%. Among the 263 (71%) patients with high sPESI, 177 (67%) were troponin-negative and 86 (33%) troponin-positive; the rate of mortality or PE recurrence at 30 days was 4.6% vs. 12.8% (p=0.015), respectively. Overall, risk assessment with a troponin test (hazard ratio [HR] 3.39, 95% confidence interval [CI] 1.38–8.37; p=0.008) maintained its prognostic value for mortality or PE recurrence when adjusted for sPESI (HR 5.80, 95%CI 0.76–44.10; p=0.09). The combination of sPESI with a troponin test resulted in a greater area under the receiver-operating characteristic curve (HR 0.72, 95% CI 0.63–0.81) than sPESI alone (HR 0.63, 95% CI 0.57–0.68) (p=0.023). In conclusion, although cardiac troponin testing may not be required in patients with a low sPESI, it adds prognostic value for early death and recurrence for patients with a high sPESI.

Keywords

Pulmonary embolism - risk stratification - Pulmonary Embolism Severity Index - cardiac troponin

• References

• 1 Kasper W, Konstantinides S, Geibel A. et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997; 30: 1165-1171.
• 2 Kucher N, Rossi E, De Rosa M. et al. Massive pulmonary embolism. Circulation. 2006; 113: 577-582.
• 3 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386-1389.
• 4 Kucher N, Rossi E, De Rosa M. et al. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher. Arch Intern Med 2005; 165: 1777-1781.
• 5 Ribeiro A, Lindmarker P, Juhlin-Dannfelt A. et al. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J 1997; 134: 479-487.
• 6 Stein PD, Matta F, Janjua M. et al. Outcome in stable patients with acute pulmonary embolism who had right ventricular enlargement and/or elevated levels of troponin I. Am J Cardiol 2010; 106: 558-563.
• 7 Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 2007; 116: 427-433.
• 8 Binder L, Pieske B, Olschewski M. et al. N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 2005; 112: 1573-1579.
• 9 Konstantinides S, Geibel A, Olschewski M. et al. Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism. Circulation 2002; 106: 1263-1268.
• 10 Kostrubiec M, Pruszczyk P, Bochowicz A. et al. Biomarker-based risk assessment model in acute pulmonary embolism. Eur Heart J 2005; 26: 2166-2172.
• 11 Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation 2003; 107: 2545-2547.
• 12 Lankeit M, Friesen D, Aschoff J. et al. Highly sensitive troponin T assay in normotensive patients with acute pulmonary embolism. Eur Heart J 2010; 31: 1836-1844.
• 13 Meyer T, Binder L, Hruska N. et al. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol 2000; 36: 1632-1636.
• 14 ten Wolde M, Tulevski II, Mulder JW. et al. Brain natriuretic peptide as a predictor of adverse outcome in patients with pulmonary embolism. Circulation 2003; 107: 2082-2084.
• 15 Torbicki A, Perrier A, Konstantinides S. et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008; 29: 2276-2315.
• 16 Kearon C, Kahn SR, Agnelli G. et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (Suppl. 06) 454S-545S.
• 17 Aujesky D, Perrier A, Roy PM. et al. Validation of a clinical prognostic model to identify low-risk patients with pulmonary embolism. J Intern Med 2007; 261: 597-604.
• 18 Chan CM, Woods C, Shorr AF. The validation and reproducibility of the pulmonary embolism severity index. J Thromb Haemost 2010; 8: 1509-1514.
• 19 Fraga M, Taffe P, Mean M. et al. The inter-rater reliability of the Pulmonary Embolism Severity Index. Thromb Haemost 2010; 104: 1258-1262.
• 20 Jimenez D, Aujesky D, Moores L. et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170: 1383-1389.
• 21 Moores L, Aujesky D, Jimenez D. et al. Pulmonary Embolism Severity Index and troponin testing for the selection of low-risk patients with acute symptomatic pulmonary embolism. J Thromb Haemost 2010; 8: 517-522.
• 22 Singanayagam A, Scally C, Al-Khairalla MZ. et al. Are biomarkers additive to pulmonary embolism severity index for severity assessment in normotensive patients with acute pulmonary embolism?. QJM 2011; 104: 125-131.
• 23 Stein PD, Fowler SE, Goodman LR. et al. Multidetector Computer Tomography for Acute Pulmonary Embolism. N Engl J Med 2006; 354: 2317-2327.
• 24 Palmieri V, Gallotta G, Rendina D. et al. Troponin I and right ventricle dysfunction for risk assessment in patients with nonmassive pulmonary embolism in the Emergency Department in combination with clinically based risk score. Intern Emerg Med 2008; 3: 131-138.
• 25 Jiménez D, Aujesky D, Moores L. et al. Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism. Thorax 2011; 66: 75-81.