Published online before print September 6, 2005, doi: 10.1161/CIRCULATIONAHA.105.552216
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(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
Related Article:
Circulation 2005 112: 1520-1521.
This article has been cited by other articles:
 |
|
 |
|
  D. Jimenez, F. Uresandi, R. Otero, J. L. Lobo, M. Monreal, D. Marti, J. Zamora, A. Muriel, D. Aujesky, and R. D. Yusen Troponin-Based Risk Stratification of Patients With Acute Nonmassive Pulmonary Embolism: Systematic Review and Metaanalysis Chest, October 1, 2009; 136(4): 974 - 982. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J-C Lega, Y Lacasse, L Lakhal, and S Provencher Natriuretic peptides and troponins in pulmonary embolism: a meta-analysis Thorax, October 1, 2009; 64(10): 869 - 875. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Ray, S. Delerme, P. Jourdain, and C. Chenevier-Gobeaux Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department QJM, November 1, 2008; 101(11): 831 - 843. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Proudfoot, D. Melley, and P. L Shah Role of thrombolysis in haemodynamically stable patients with pulmonary embolism Thorax, October 1, 2008; 63(10): 853 - 854. [Full Text] [PDF]
|
|
|
|
 |
|
 Authors/Task Force Members, A. Torbicki, A. Perrier, S. Konstantinides, G. Agnelli, N. Galie, P. Pruszczyk, F. Bengel, A. J.B. Brady, D. Ferreira, 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., September 2, 2008; 29(18): 2276 - 2315. [Full Text] [PDF]
|
|
|
|
 |
|
 F. A. Klok, I. C. M. Mos, and M. V. Huisman Brain-Type Natriuretic Peptide Levels in the Prediction of Adverse Outcome in Patients with Pulmonary Embolism: A Systematic Review and Meta-analysis Am. J. Respir. Crit. Care Med., August 15, 2008; 178(4): 425 - 430. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Lankeit, T. Kempf, C. Dellas, M. Cuny, H. Tapken, T. Peter, M. Olschewski, S. Konstantinides, and K. C. Wollert Growth Differentiation Factor-15 for Prognostic Assessment of Patients with Acute Pulmonary Embolism Am. J. Respir. Crit. Care Med., May 1, 2008; 177(9): 1018 - 1025. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Stoodley, M. Cooper, and L. Thomas Acute pulmonary embolus in pregnancy: a case study highlighting the value of TTE Eur J Echocardiogr, May 1, 2008; 9(3): 406 - 409. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Jimenez, G. Diaz, J. Molina, D. Marti, J. Del Rey, S. Garcia-Rull, C. Escobar, R. Vidal, A. Sueiro, and R. D. Yusen Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism Eur. Respir. J., April 1, 2008; 31(4): 847 - 853. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Lancellotti, B. Cosyns, and L. A. Pierard Dynamic left ventricular dyssynchrony contributes to B-type natriuretic peptide release during exercise in patients with systolic heart failure Europace, April 1, 2008; 10(4): 496 - 501. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. T. Lu, T. Cai, H. Ersoy, A. G. Whitmore, R. Quiroz, S. Z. Goldhaber, and F. J. Rybicki Interval Increase in Right-Left Ventricular Diameter Ratios at CT as a Predictor of 30-day Mortality after Acute Pulmonary Embolism: Initial Experience Radiology, January 1, 2008; 246(1): 281 - 287. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J.G. Coghlan and J. Davar How should we assess right ventricular function in 2008? Eur. Heart J. Suppl., December 1, 2007; 9(suppl_H): H22 - H28. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. Palmieri, E. A. Palmieri, and A. Celentano Functional limitation and right ventricular dysfunction at 6-month follow-up in patients with non-massive pulmonary embolism: useful outcomes for testing therapy of acute submassive pulmonary embolism? Eur. Heart J., October 2, 2007; 28(20): 2430 - 2431. [Full Text] [PDF]
|
|
|
|
 |
|
 C. Becattini, M. C. Vedovati, and G. Agnelli Prognostic Value of Troponins in Acute Pulmonary Embolism: A Meta-Analysis Circulation, July 24, 2007; 116(4): 427 - 433. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Jimenez, R. D. Yusen, R. Otero, F. Uresandi, D. Nauffal, E. Laserna, F. Conget, M. Oribe, M. A. Cabezudo, and G. Diaz Prognostic Models for Selecting Patients With Acute Pulmonary Embolism for Initial Outpatient Therapy Chest, July 1, 2007; 132(1): 24 - 30. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. J. Carlbom and B. L. Davidson Pulmonary Embolism in the Critically Ill Chest, July 1, 2007; 132(1): 313 - 324. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Abroug, L. Ouanes-Besbes, N. Nciri, N. Sellami, F. Addad, K. B. Hamda, A. B. Amor, M. F. Najjar, and J. Knani Association of Left-Heart Dysfunction with Severe Exacerbation of Chronic Obstructive Pulmonary Disease: Diagnostic Performance of Cardiac Biomarkers Am. J. Respir. Crit. Care Med., November 1, 2006; 174(9): 990 - 996. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Kostrubiec, A. Kaczynska, and P. Pruszczyk Risk assessment in acute pulmonary embolism Eur. Heart J., June 1, 2006; 27(11): 1384 - 1384. [Full Text] [PDF]
|
|
|
|
 |
|
 W.H. W. Tang and G. S. Francis The Year in Heart Failure J. Am. Coll. Cardiol., December 6, 2005; 46(11): 2125 - 2133. [Full Text] [PDF]
|
|
|
|
|
|
E. Giannitsis and H. A. Katus Risk Stratification in Pulmonary Embolism Based on Biomarkers and Echocardiography Circulation, September 13, 2005; 112(11): 1520 - 1521. [Full Text] [PDF]
|
|