Published online before print September 6, 2005, doi: 10.1161/CIRCULATIONAHA.105.552216
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(Circulation. 2005;112:1573-1579.)
© 2005 American Heart Association, Inc.
Heart Failure |
N-Terminal Pro–Brain Natriuretic Peptide or Troponin Testing Followed by Echocardiography for Risk Stratification of Acute Pulmonary Embolism
From the Departments of Clinical Chemistry (L.B.) and Cardiology and Pulmonary Medicine (B.P., B.K., C.R., S.K.), Georg August University of Goettingen, Goettingen, Germany; and the Departments of Biostatistics (M.O.) and Cardiology and Angiology (A.G.), Albert Ludwig University of Freiburg, Freiburg, Germany.
Correspondence to Stavros Konstantinides, MD, Department of Cardiology and Pulmonary Medicine, Georg August University of Goettingen, Robert Koch Strasse 40, D-37099 Goettingen, Germany. E-mail skonstan{at}med.uni-goettingen.de
Received March 28, 2005; revision received May 13, 2005; accepted May 17, 2005.
Background— Brain natriuretic peptide (BNP) and N-terminal (NT)-proBNP have recently emerged as promising parameters for risk assessment in acute pulmonary embolism (PE). However, their positive predictive value is low, and the prognostic implications of NT-proBNP or troponin elevation alone are questionable.
Methods and Results— To determine whether the combination of NT-proBNP testing with echocardiography may identify both low-risk and high-risk patients with PE, we examined 124 consecutive patients with proved PE. All underwent echocardiography on admission to detect right ventricular dysfunction. NT-proBNP and troponin concentrations were measured in one core laboratory. The primary end point was death or major in-hospital complications. The cutoff level of 1000 pg/mL had a high negative predictive value (95% for a complicated course, 100% for death), but NT-proBNP 
1000 pg/mL did not independently predict an adverse outcome. Combination of NT-proBNP testing with echocardiography identified 3 major risk groups. A positive echocardiogram was associated with a 12-fold elevation in complication risk compared with patients with low NT-proBNP (P=0.002), whereas NT-proBNP elevation without right ventricular dysfunction on echocardiography only slightly increased the risk of an adverse outcome (P=0.17). The combination of cardiac troponin testing with echocardiography yielded similar complication rates in the lowest-risk group and a similar magnitude of risk elevation for the highest-risk patients, but it also increased the number of intermediate-risk groups.
Conclusions— Our results support a simple risk stratification algorithm for patients with PE, with the use of NT-proBNP or troponin testing as an initial step that should be followed by echocardiography if elevated levels of the biomarker are found.
Key Words: echocardiography • embolism • natriuretic peptides • prognosis • pulmonary heart disease
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