Copyright © 2003 by the European Society of Cardiology.
Regular Articles
Incremental prognostic value of troponin I and echocardiography in patients with acute pulmonary embolism
Cardiology, Swiss Cardiovascular Center, University Hospital, 3010 Bern, Switzerland
* Correspondence to: Nils Kucher, MD, Cardiovascular Division, VTEResearch Group, Brigham and Women‘s Hospital, Harvard MedicalSchool, 75 Francis Street, Boston, MA 02115, USA. Tel: +1 617 732 69 86; fax: +1 617 738 7652
E-mail address: nkucher{at}partners.org
Received 24 January 2003; revised 24 June 2003; accepted 26 June 2003
Background To test the hypothesis that troponin I and echocardiography have an incremental prognostic value in patients with pulmonary embolism (PE).
Methods and results In 91 patients with acute PE, echocardiography was performed within 4h of admission. Troponin I levels were obtained on admission and 12h thereafter. The 0.06µg/l troponin I cut-off level was identified as the most useful, high-sensitivity cut-off level for the prediction of adverse outcome by receiver operating characteristic analysis with a sensitivity and specificity of 86%, respectively. Twenty-eight (31%) patients had elevated troponin I levels (4.9±3.8µg/l). Twenty-one (23%) patients had adverse clinical outcomes including in-hospital death in five, cardiopulmonary resuscitation in four, mechanical ventilation in six, pressors in 14, thrombolysis in 14, catheter fragmentation in three, and surgical embolectomy in three. The area under the receiver operating characteristic curve from multivariate regression models for predicting adverse outcome without troponin I and echocardiography (0.765), with troponin I (0.890) or echocardiography alone (0.858), and the combination of both tests (0.900) was incremental. Three-month survival rate was highest in patients with both a normal troponin I level and a normal echocardiogram (98%). Positive predictive value for adverse clinical outcomes of the combination of echocardiography and troponin I was higher (75% (95%CI 55–88%)) compared with each test alone (echocardiography: 41%, 95% CI 28–56%; troponin I: 64%, 95% CI 46–79%).
Conclusions While troponin I measurements added most of the prognostic information for identifying high-risk patients, a normal echocardiogram combined with a negative troponin I level was most useful to identify patients at lowest risk for early death.
Key Words: Pulmonary embolism • prognosis • echocardiography
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