Optimized definition of right ventricular dysfunction on computed tomography for risk stratification of pulmonary embolism.

OBJECTIVES: There is an ongoing discussion on the optimal right to left (RV/LV) diameter ratio threshold and the best definition of RV dysfunction on computed tomography pulmonary angiography (CTPA) for risk assessment of pulmonary embolism (PE). METHODS: On routine diagnostic CTPA, volumetric and diameter measurements (axial and reconstructed views) of the ventricles and reflux of contrast medium into the inferior vena cava (IVC) and hepatic veins were assessed in consecutive PE patients enrolled in a prospective single-center registry. In-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration. RESULTS: Of 609 patients (median age, 69 [IQR, 56-77] years; 47 % male) included in the analysis, 68 patients (11.2 %) had an adverse outcome and 35 (5.7 %) died. While neither a RV/LV volume ratio ≥1.0 nor RV/LV diameter ratios ≥1.0 were able to predict an adverse outcome, higher thresholds increased specificity. Further, neither volumetric measurements nor reconstruction of images provided superior prognostic information compared to RV/LV ratios measured in axial planes. The combination of an axial RV/LV diameter ratio ≥1.5 with substantial reflux of contrast medium was present in 134 patients (22 %) and associated with the best prognostic performance to predict an adverse outcome in unselected (OR 3.7 [95 % CI, 2.0-6.6]) and normotensive (OR 2.8 [95 % CI, 1.1-6.7]) patients. CONCLUSION: A new definition of RV dysfunction (axial RV/LV diameter ratio ≥1.5 and substantial reflux of contrast medium to the IVC and hepatic veins) allows an optimized CTPA-based prediction of PE-related adverse outcome.

Impact of thyroid dysfunction on short-term outcomes and long-term mortality in patients with pulmonary embolism.

BACKGROUND: A large body of evidence suggest an impact of thyroid function on outcomes of cardiovascular diseases, but results for acute pulmonary embolism (PE) are sparse. METHODS: We analysed the impact of hypothyroidism as well as hyperthyroidism on the short and long-term outcomes of patients with acute PE. The impact was compared to the group of euthyroid PE patients as reference group. RESULTS: Overall, 831 PE patients (median age 69 [IQR 56-77] years; 52.2% females) were analysed. Among these, 734 patients (88.3%) were classified as euthyroid, 40 (4.8%) as hypothyroid and 57 (6.9%) as hyperthyroid. PE patients with hypothyroidism had higher rates of adverse in-hospital outcomes (37.5% vs. 11.6%, P < 0.001), PE-related (22.5% vs. 4.8%, P < 0.001) and all-cause in-hospital death (25.0% vs. 6.8%, P < 0.001), whereas hyperthyroidism did not affect in-hospital outcomes. Long-term mortality was higher in hypothyroidism (52.5% vs. 28.9%, P = 0.002) and hyperthyroidism (43.9% vs. 28.9%, P = 0.018) compared to euthyroid function. In the 750 normotensive PE patients, hyperthyroidism affected adverse in-hospital outcome (OR 2.58 [95%CI 1.12-5.97], P = 0.026) and PE-related in-hospital mortality (OR 3.50 [95%CI 1.10-11.17], P = 0.035) in comparison to euthyroid PE patients, while hypothyroidism showed no influence. Elevated fT4 (HR 1.75 [95%CI 1.16-2.63], P = 0.007) and reduced fT3 values (HR 2.51 [95%CI 1.48-4.28], P = 0.001) were associated with increased long-term mortality. CONCLUSION: Thyroid dysfunction had a substantial impact on short and long-term outcomes of patients with acute PE. Elevated fT4 and reduced fT3 values were significantly associated with increased long-term mortality in normotensive PE patients.

Prognostic value of right atrial dilation in patients with pulmonary embolism.

AIMS: Right atrial (RA) dilation and stretch provide prognostic information in patients with cardiovascular diseases. We investigated the prevalence, confounding factors and prognostic relevance of RA dilation in patients with pulmonary embolism (PE). METHODS: Overall, 609 PE patients were consecutively included in a prospective single-centre registry between September 2008 and August 2017. Volumetric measurements of heart chambers were performed on routine non-electrocardiographic-gated computed tomography and plasma concentrations of mid-regional pro-atrial natriuretic peptide (MR-proANP) measured on admission. An in-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration. RESULTS: Patients with an adverse outcome (11.2%) had larger RA volumes (median 120 (interquartile range 84-152) versus 102 (78-134) mL; p=0.013), RA/left atrial (LA) volume ratios (1.7 (1.2-2.4) versus 1.3 (1.1-1.7); p<0.001) and MR-proANP levels (282 (157-481) versus 129 (64-238) pmol·L-1; p<0.001) compared to patients with a favourable outcome. Overall, 499 patients (81.9%) had a RA/LA volume ratio ≥1.0 and a calculated cut-off value of 1.8 (area under the curve 0.64, 95% CI 0.56-0.71) predicted an adverse outcome, both in unselected (OR 3.1, 95% CI 1.9-5.2) and normotensive patients (OR 2.7, 95% CI 1.3-5.6). MR-proANP ≥120 pmol·L-1 was identified as an independent predictor of an adverse outcome, both in unselected (OR 4.6, 95% CI 2.3-9.3) and normotensive patients (OR 5.1, 95% CI 1.5-17.6). CONCLUSIONS: RA dilation is a frequent finding in patients with PE. However, the prognostic performance of RA dilation appears inferior compared to established risk stratification markers. MR-proANP predicted an in-hospital adverse outcome, both in unselected and normotensive PE patients, integrating different prognostic relevant information from comorbidities.