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Prognostic Factors for Pulmonary Embolism

The PREP Study, A Prospective Multicenter Cohort Study

¹ Service de Pneumologie et Soins Intensifs, and ² Unité de Recherche Clinique, INSERM CIE 4, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; ³ Hôpital Ambroise Paré, Service de Réanimation médicale, Assistance Publique Hôpitaux de Paris, Boulogne, France; ⁴ Université Européenne de Bretagne, Université de Brest, EA3878, IFR148, and Departement de Médecine Interne et de Pneumologie, CHU de La Cavale Blanche, Brest, France; ⁵ Hôpital Trousseau, Service de Cardiologie A, CHRU de Tours, France; ⁶ CHU Jean Minjoz, Service de Cardiologie, Besançon; France ⁷ Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Acute Medicine Department, Accidents and Emergency Unit, Brussels, Belgium; ⁸ CHU d'Angers, Service d'accueil des urgences, Angers, France; ⁹ Hôpital Antoine Béclère, service de pneumologie, Assistance Publique Hôpitaux de Paris, Clamart, France; ¹⁰ Geneva University Hospital, Division of General Internal Medicine, Geneva, Switzerland; ¹¹ Hôtel Dieu de Paris, service de pneumologie, Assistance Publique Hôpitaux de Paris, Paris, France; ¹² CHU St-Etienne Bellevue, service des urgences et réanimation médicale, St-Etienne, France; ¹³ Hôpital Européen Georges Pompidou, service de biochimie, Assistance Publique Hôpitaux de Paris, Paris, France

Correspondence and requests for reprints should be addressed to Olivier Sanchez, M.D., Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, 20 rue Leblanc 75015 Paris, France. E-mail: olivier.sanchez{at}egp.aphp.fr

Rationale: The short-term prognosis of pulmonary embolism (PE) depends on hemodynamic status and underlying disease. The prognostic value of right ventricular dysfunction and injury is less well established.

Objectives: To evaluate prognostic factors of PE in a multicenter prospective cohort study.

Methods: Echocardiography, brain natriuretic peptide (BNP), N-terminal–proBNP and cardiac troponin I measurements were done on admission of 570 consecutive patients with an acute PE. A predictive model was based on independent predictors of 30-day adverse events defined as death, secondary cardiogenic shock, or recurrent venous thromboembolism.

Measurements and Main Results: At 30 days, 42 patients (7.4%; 95% confidence interval [CI], 5.5–9.8%) had adverse events. On multivariate analysis, altered mental state (odds ratio [OR] 6.8; 95% confidence interval [CI], 2.0–23.3), shock on admission (OR 2.8; 95% CI, 1.1–7.5), cancer (OR 2.9; 95% CI, 1.2–6.9), BNP (OR 1.3 for an increase of 250 ng/L; 95% CI, 1.1–1.6) and right to left ventricle diameter ratio (OR 1.2 for an increase of 0.1; 95% CI, 1.1–1.4) were associated with 30-days of adverse events. The predictive performance of the model was good (area under receiver operating characteristics curve 0.84 [95% CI, 0.78–0.90]), making it possible to develop a bedside prognostic score.

Conclusions: BNP and echocardiography may be useful determinants of the short-term outcome for patients with PE, together with clinical findings. Patients with PE can be stratified according to the initial risk of adverse outcome, using a simple score based on clinical, echocardiographic, and biochemical variables.

Key Words: echocardiography • natriuretic peptides • prognosis • pulmonary embolism

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Recent guidelines suggest that initial risk stratification of patients with pulmonary embolism (PE) should be based on the presence of shock and hypotension. Further stratification based on imaging or biochemical markers of right ventricular dysfunction or injury has been suggested, but current evidence is insufficient to make definitive recommendations on this point. What This Study Adds to the Field BNP and echocardiography may be useful determinants of the short-term outcome for patients with PE, together with clinical findings. PE patients may be stratified according to the initial risk of adverse outcome, using a simple score based on clinical, echocardiographic and biochemical variables.

 

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