Highlights
- •Most intermediate-risk PE patients with RV involvement have a benign course.
- •Severe RV dysfunction and syncope were associated with worse outcomes.
- •A combined score might stratify those patients with a more benign clinical course.
Abstract
Background
Intermediate-risk pulmonary embolism (PE) patients present a therapeutic dilemma.
While some are at risk for developing adverse events, possibly requiring escalation
therapy, most will have a benign course. Our aim was to define predictors which will
identify those patients who will not deteriorate despite the presence of RV involvement.
Methods
We evaluated 179 consecutive intermediate-risk PE patients (47% males; mean age: 66 ± 16 years),
allocating them to those who did and did not need escalation therapy and evaluating
the predictors for deterioration. We then formulated a score to distinguish between
those who would not require escalation therapy.
Results
Twenty-six patients (15%) required escalation therapy which was associated with significantly
more episodes of syncope (42% vs. 15%, p = 0.001), higher D-Dimer levels (10,810 ± 19,147
vs. 3816 ± 6255, p < 0.001), echocardiographic evidence of severe right ventricular
(RV) dysfunction (42% vs. 19%, p < 0.01), or a higher RV/left ventricular (LV) diameter
ratio on computed tomography (CT) (1.9 ± 0.6 vs. 1.46 ± 0.5, p < 0.001). On multivariate
analysis the presence of syncope (HR 2.8 CI 1.1–7.1) and severe RV dysfunction on
echocardiography (HR 3.5 CI 1.4–9.3) were found to be independent predictors for escalation
therapy. A combined score of 1 was associated with only a 1.9% risk for escalation,
while a maximum score of 4 was associated with a 57% risk for escalation therapy (P
for trend<0.001). Conclusions: A small but significant number of intermediate-risk
PE patients required escalation therapy. A combined score comprising clinical, imaging,
and laboratory parameters might aid in further risk stratification, identifying those
intermediate risk PE patients with a more benign clinical course.
Keywords
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Article info
Publication history
Published online: May 01, 2019
Accepted:
April 25,
2019
Received in revised form:
March 28,
2019
Received:
December 18,
2018
Identification
Copyright
© 2019 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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Access this article on ScienceDirectLinked Article
- Patients with acute pulmonary embolism at intermediate risk for death: Can we further stratify?European Journal of Internal MedicineVol. 65
- PreviewInternational Scientific Societies (European Society of Cardiology, American Heart Association, American College of Chest Physician) recommend stratification for the risk of short-term death to drive acute clinical care in patients with acute pulmonary embolism (PE) [1–3]. However, no consensus exists on the optimal strategy for risk stratification beyond the classification in hemodynamically stable and unstable patients. The European Society of Cardiology (ESC) proposed a comprehensive strategy for risk stratification that includes both clinical and instrumental criteria [1].
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