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Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism
demonstrated that the probability of 30-day event-free survival was higher in the heparin-plus-alteplase group (p⫽0.005). This beneficial effect was due to reduction in the incidence of treatment escalation in the heparin plusalteplase group (10.2% vs. 24.6%, p⫽0.004) with similar in-hospital mortality in both groups (3.4 percent in the heparin-plus-alteplase group and 2.2% in the heparin-plusplacebo group, p⫽0.71). The relative risk of primary endpoint was 2.6 times higher in the heparin plus placebo group compared to that in heparin plus alteplase (p⫽0.006). This beneficial effect with the combination of heparin plus alteplase was seen with no occurrence of fatal bleeding or cerebral bleeding. Conclusions: The use of heparin plus alteplase improves clinical outcomes in hemodynamically stable patients having acute submassive pulmonary embolism. Perspective: While thrombolysis is currently indicated only in patients with acute pulmonary embolism with hemodynamic instability, this study supports expanding its use for the treatment of patients with acute pulmonary embolism with right ventricular dysfunction and normal systemic arterial pressure. The potential for benefit in such patients results from prevention of future pulmonary hypertension, prevention of recurrence of pulmonary embolism secondary to clot lysis in the pulmonary and deep venous circulation and rapid improvement in right ventricular function. RM
odds ratio for in-hospital mortality in patients with cTnI 0.07–1.5 ng/mL was 7.2 (95% confidence interval 0.7– 72.0, p⫽0.09) and that for patients with cTnI ⬎1.5 ng/mL was 16.9 (1.6 –177.7, p⫽0.02). The odds ratios for inhospital death for cTnT levels between 0.04 –1.0 ng/mL was 2.3 (95% confidence interval 0.2–27.4, p⫽0.50 [referent cTnT ⬍0.04 ng/mL]) and for cTnT ⬎1.0 ng/mL was 6.5 (95% confidence interval 1.1–38.2, p⫽0.04 [referent cTnT levels ⬍0.04 ng/mL]). A similar gradient of increased risk of a complicated in-hospital course was seen with increasing levels of cTnI and cTnT. Conclusions: cTnI and cTnT may be useful for the riskstratification of patients with PE and may help in optimizing management in these patients. Perspective: In patients with chest pain syndromes, acute PE should be considered in the differential diagnosis of elevated cardiac troponins. Further, while negative cardiac troponins is associated with very low risk of in-hospital adverse events in patients with PE, elevation of these enzymes is associated with a much greater risk. Appropriate patients with PE and elevation of cardiac enzymes should receive aggressive treatment including in selected individuals possibly thrombolytic therapy to improve outcomes. RM
Normal D-Dimer Levels in Emergency Department Patients Suspected of Acute Pulmonary Embolism
Importance of Cardiac Troponins I and T in Risk Stratification of Patients With Acute Pulmonary Embolism
Dunn KL, Wolf JP, Dorfman DM, Fitzpatrick P, Baker JL, Goldhaber SZ. J Am Coll Cardiol 2002;40:1475– 8. Study Question: What is the reliability of plasma D-dimer ELISA as a screening test for acute pulmonary embolism (PE), and will physicians accept a normal value without further testing such as a lung scan or CT based or invasive pulmonary angiography. Methods: A D-dimer assay was obtained in all patients suspected of a PE in the ER and the results were available within 2 hours around-the-clock. A normal D-dimer was defined as equal to or less than 500 ng/mL. Records were reviewed to determine whether additional tests were obtained and whether the final diagnosis was a PE. Results: 1106 D-dimer assays were obtained during the year 2000, 559 were elevated and 547 were normal. Only 2 of the 427 had a PE with a normal D-dimer or negative predictive value of ⬎99.6%. 53 of 55 had an elevated level, a sensitivity of 96.4% (95%CI 87.5–99.6%). The specificity was 52% and positive predictive value 9.5%. During a 6-month period after the ER visit, no additional patients with a normal D-dimer were diagnosed with a PE. Despite widespread acceptance of the D-dimer, 24% of patients with normal values underwent additional tests for PE. Conclusions: The D-dimer ELISA has a high negative predictive value for excluding PE in the ER. Considerable cost savings without loss of diagnostic accuracy can be obtained
Konstantinides S, Geibel A, Olschewski M, et al. Circulation 2002;106;1263– 8. Study Question: What is the importance of cardiac troponins I (cTnI) and T (cTnT) in the risk stratification of patients with acute pulmonary embolism (PE)? Methods: 106 consecutive patients with acute PE confirmed by either a ventilation-perfusion lung scan, spiral computerized tomography or pulmonary angiography had their blood drawn at admission as well as 4, 8 and 24 hours for determination of cardiac troponins. Results: Elevation of cTnI (41% of patients) or cTnT (37% of patients) was significantly associated with ECG signs of right ventricular strain or echocardiographic evidence of right ventricular dysfunction (p⫽0.001 and p⬍0.05, respectively). In-hospital mortality and complications were both higher in the patients with elevated cTnI or cTnT than in those without such elevation. The negative predictive value of cTnI and cTnT for major clinical events (death or in-hospital complications) was 92–93%, respectively. Importantly, in-hospital mortality, the rate of complications and the incidence of recurrent PE increased with increasing values of cardiac troponins. Thus, when compared to patients with normal cTnI values (⬍0.07 ng/mL), the adjusted
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odds ratio for in-hospital mortality in patients with cTnI 0.07–1.5 ng/mL was 7.2 (95% confidence interval 0.7– 72.0, p⫽0.09) and that for patients with cTnI ⬎1.5 ng/mL was 16.9 (1.6 –177.7, p⫽0.02). The odds ratios for inhospital death for cTnT levels between 0.04 –1.0 ng/mL was 2.3 (95% confidence interval 0.2–27.4, p⫽0.50 [referent cTnT ⬍0.04 ng/mL]) and for cTnT ⬎1.0 ng/mL was 6.5 (95% confidence interval 1.1–38.2, p⫽0.04 [referent cTnT levels ⬍0.04 ng/mL]). A similar gradient of increased risk of a complicated in-hospital course was seen with increasing levels of cTnI and cTnT. Conclusions: cTnI and cTnT may be useful for the riskstratification of patients with PE and may help in optimizing management in these patients. Perspective: In patients with chest pain syndromes, acute PE should be considered in the differential diagnosis of elevated cardiac troponins. Further, while negative cardiac troponins is associated with very low risk of in-hospital adverse events in patients with PE, elevation of these enzymes is associated with a much greater risk. Appropriate patients with PE and elevation of cardiac enzymes should receive aggressive treatment including in selected individuals possibly thrombolytic therapy to improve outcomes. RM
Normal D-Dimer Levels in Emergency Department Patients Suspected of Acute Pulmonary Embolism
Importance of Cardiac Troponins I and T in Risk Stratification of Patients With Acute Pulmonary Embolism
Dunn KL, Wolf JP, Dorfman DM, Fitzpatrick P, Baker JL, Goldhaber SZ. J Am Coll Cardiol 2002;40:1475– 8. Study Question: What is the reliability of plasma D-dimer ELISA as a screening test for acute pulmonary embolism (PE), and will physicians accept a normal value without further testing such as a lung scan or CT based or invasive pulmonary angiography. Methods: A D-dimer assay was obtained in all patients suspected of a PE in the ER and the results were available within 2 hours around-the-clock. A normal D-dimer was defined as equal to or less than 500 ng/mL. Records were reviewed to determine whether additional tests were obtained and whether the final diagnosis was a PE. Results: 1106 D-dimer assays were obtained during the year 2000, 559 were elevated and 547 were normal. Only 2 of the 427 had a PE with a normal D-dimer or negative predictive value of ⬎99.6%. 53 of 55 had an elevated level, a sensitivity of 96.4% (95%CI 87.5–99.6%). The specificity was 52% and positive predictive value 9.5%. During a 6-month period after the ER visit, no additional patients with a normal D-dimer were diagnosed with a PE. Despite widespread acceptance of the D-dimer, 24% of patients with normal values underwent additional tests for PE. Conclusions: The D-dimer ELISA has a high negative predictive value for excluding PE in the ER. Considerable cost savings without loss of diagnostic accuracy can be obtained
Konstantinides S, Geibel A, Olschewski M, et al. Circulation 2002;106;1263– 8. Study Question: What is the importance of cardiac troponins I (cTnI) and T (cTnT) in the risk stratification of patients with acute pulmonary embolism (PE)? Methods: 106 consecutive patients with acute PE confirmed by either a ventilation-perfusion lung scan, spiral computerized tomography or pulmonary angiography had their blood drawn at admission as well as 4, 8 and 24 hours for determination of cardiac troponins. Results: Elevation of cTnI (41% of patients) or cTnT (37% of patients) was significantly associated with ECG signs of right ventricular strain or echocardiographic evidence of right ventricular dysfunction (p⫽0.001 and p⬍0.05, respectively). In-hospital mortality and complications were both higher in the patients with elevated cTnI or cTnT than in those without such elevation. The negative predictive value of cTnI and cTnT for major clinical events (death or in-hospital complications) was 92–93%, respectively. Importantly, in-hospital mortality, the rate of complications and the incidence of recurrent PE increased with increasing values of cardiac troponins. Thus, when compared to patients with normal cTnI values (⬍0.07 ng/mL), the adjusted
ACC CURRENT JOURNAL REVIEW Jan/Feb 2003
17