European Heart Journal Advance Access originally published online on April 7, 2006
European Heart Journal 2006 27(11):1384; doi:10.1093/eurheartj/ehi865
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Risk assessment in acute pulmonary embolism
Department of Internal Medicine, Hypertension, and Angiology
The Medical University of Warsaw
Banacha 1a
02-097 Warsaw
Poland
ska
Department of Internal Medicine, Hypertension, and Angiology
The Medical University of Warsaw
Banacha 1a
02-097 Warsaw
Poland
Department of Internal Medicine, Hypertension, and Angiology
The Medical University of Warsaw
Banacha 1a
02-097 Warsaw
Poland
Tel: +48 22 5992828
Fax: +48 22 5991828
E-mail address: piotr.pruszczyk{at}amwaw.edu.pl
We read with great interest the paper by Aujesky et al.,1 validating the prognostic model comprising 11 routinely available clinical parameters in patients with pulmonary embolism (PE). However, the presented model is of low cost but also complex. Moreover, some parameters like presence of cancer, altered mental status, severity of heart failure, and chronic lung disease, can be difficult to assess and are observer-dependent. It is also remarkable that the presented model does not include increased creatinine level reflecting impaired renal function, which was reported to be an important prognostic factor in acute PE patients.2,3 According to the authors, this model effectively identifies patients at low risk of mortality, however, the high-risk group of fatal outcome is not unequivocally indicated. In acute PE, the medical status depends on the haemodynamic compromise mostly determined by the level of right ventricle overload. Natriuretic peptides and troponin are well-established markers of cardiovascular mortality. It is generally accepted that they reflect the severity of acute heart dysfunction in PE.4 In 2005, there were two papers that proposed including biomarkers into risk assessment. Binder et al.5 observed that NT-proBNP cut-off level of 1000 pg/mL had a high negative predictive value (95% for a complicated course, 100% for death), whereas troponin combined with echocardiography improved the prediction of outcome in intermediate-risk group. The second study also proved that low levels of NT-proBNP predict favourable outcome.3 Interestingly, mortality related to PE in patients with elevated NT-proBNP and high troponin T was similar to the death rate observed in a group of patients with clinically massive embolism and reached 33%. Importantly, both biomarkers helped to stratify 40-day prognosis in acute PE for both low and high-risk groups. Therefore, on the basis of the biomarkers model, stratifying the risk in PE seems to be the option, which provides objective and accurate prognosis assessment.
References
- Aujesky D, Roy PM, Le Manach CP, Verschuren F, Meyer G, Obrosky DS, Stone RA, Cornuz J, Fine MJ. (2006) Validation of a model to predict adverse outcomes in patients with pulmonary embolism. Eur Heart J 27:476–481.
[Abstract/Free Full Text] - Goldhaber SZ, Visani L, De Rosa M. (1999) Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 353:1386–1389.[CrossRef][ISI][Medline]
- Kostrubiec M, Pruszczyk P, Bochowicz A, Pacho R, Szulc M, Kaczynska A, Styczynski G, Kuch-Wocial A, Abramczyk P, Bartoszewicz Z, Berent H, Kuczynska K. (2005) Biomarker-based risk assessment model in acute pulmonary embolism. Eur Heart J 26:2166–2172.
[Abstract/Free Full Text] - Pruszczyk P, Kostrubiec M, Bochowicz A, Styczynski G, Szulc M, Kurzyna M, Fijalkowska A, Kuch-Wocial A, Chlewicka I, Torbicki A. (2003) N-terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism. Eur Respir J 22:649–653.
[Abstract/Free Full Text] - Binder L, Pieske B, Olschewski M, Geibel A, Klostermann B, Reiner C, Konstantinides S. (2005) N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 112:1573–1579.
[Abstract/Free Full Text]
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