Importance of cardiac biomarkers in risk stratification in acute pulmonary embolism.

At present there is consent that patients with acute pulmonary embolism (APE) and hemodynamic instability have poor prognosis and benefit from thrombolytic therapy or embolectomy, whereas hemodynamically stable patients without echocardiographic signs of right ventricular overload/dysfunction (RVO) have good prognosis and should be treated with anticoagulation alone. The optimal treatment for stable APE patients with RVO remains a challenge, and cardiac biomarkers can probably add to risk stratification and therapeutic decision making. Troponins are indicators of irreversible cardiac cell injury, and in patients with APE even a moderate rise of the blood troponin level correlates with RVO, hemodynamic instability and cardiogenic shock. However, the positive predictive value of cardiac troponins is relatively low. It can be increased when the results of troponins and echocardiography are combined. The clinical benefits of cardiac troponins result foremost from the high negative predictive value of in-hospital events, including death. Likewise, elevated levels of natriuretic peptides such as BNP and NT-proBNP, caused by increased right ventricular stress, show close association with RVO and with increased in-hospital risk. Instead, the low level of natriuretic biomarkers indicates an uncomplicated outcome of APE. There are some proposals of algorithms that combine both biomarkers and echocardiography for risk stratification. The principal aim of ongoing studies is to find patients with hemodynamically stable APE who can be candidates for thrombolytic therapy. The usefulness of biomarkers in long-term prognosis and their value to identify APE patients in whom chronic thromboembolic pulmonary hypertension can develop should also be confirmed.

Electrocardiographic signs of right ventricular overload in patients who underwent pulmonary embolism event(s). Are they useful in diagnosis of chronic thromboembolic pulmonary hypertension?

Diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) remains a major clinical problem. An attempt was made to learn whether electrocardiography has the potential to alleviate that problem. Sensitivity, specificity, negative and positive predictive value as well as a likelihood ratio of electrocardiogram (ECG) signs of right ventricular overload (RVO) were determined in 56 patients with chronic pulmonary embolism and a mean pulmonary artery pressure (mPAP) ranging from 15 to 80 mm Hg. CPE was recognized as the only disease in 44 patients (Group A) whereas the remaining 12 CPE patients suffered from concomitant cardiac and pulmonary diseases (Group B). Thirty three (59%) of the patients were diagnosed with CTEPH (mPAP exceeding 30 mm Hg). Twelve ECG signs of RVO were identified in the entire population of patients. At least a single ECG sign of RVO was found in 72% of the patients and 7 ECG signs were found exclusively in CTEPH patients. Negative T wave in precordial V1-V5 leads, negative T wave in II, III, aVF, pulmonary P wave and right axis deviation >90% occurred with the highest incidence that was determined to be 43%, 32%, 30%, and 30% respectively. These ECG signs of RVO had positive predictive value of those signs ranged from 80 to 100% in Group A and 25 to 75% in Group B, whereas their negative predictive value ranged from 44 to 76% and from 66.5 to 87.5% respectively. It is concluded that ECG signs of RVO appear to have the potential to aid in diagnosing CTEPH in the patients who underwent acute embolic event in the past.

[Electrocardiographic signs of right ventricular overload useful in improving diagnosis of chronic thromboembolic pulmonary hypertension (CTE-PH) in patients with chronic exertional dyspnea]. / Elektrokardiograficzne cechy przeciazenia prawej komory serca przydatne w rozpoznawaniu nadcisnienia plucnego na tle przewleklej choroby zakrzepowo-zatorowej u chorych z przewlekla dusznoscia wysilkowa.

The early recognition of chronic thromboembolic pulmonary hypertension (CTE-PH) is troublesome because of "honey moon" period with chronic dyspnea on exertion as the only one symptom. To find if routine electrocardiography may be useful in improving the diagnosis, value of right ventricular overload (RVO) signs in recognition echocardiographically determined chronic pulmonary hypertension (CPH) and angiographically confirmed CTE-PH in 90 consecutive patients hospitalized due to chronic exertional dyspnea was studied. CPE was found in 76.5% and CTE-PH in 33% of those patients, at least one of twelve founded electrocardiographic signs of RVO was present in 50% patients. The most frequently occurred signs: negative T wave in lead V1-V6, right axis deviation and pulmonale P wave as well as 9 other occurred at frequency below 20% signs of RVO had low to medium sensitivity and negative predictive value and 80-90% positive predictive value for diagnosing CPE and 90-100% positive predictive value for diagnosing CTE-PH. It was concluded that in patients with chronic exertional dyspnea electrocardiographic signs of RVO may be useful in initial diagnosing of CPH and CTE-PH in particular.