Chest
Volume 123, Issue 6, June 2003, Pages 1947-1952
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Clinical Investigations
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Cardiac Troponin T Monitoring Identifies High-Risk Group of Normotensive Patients With Acute Pulmonary Embolisma

https://doi.org/10.1378/chest.123.6.1947Get rights and content

Study objectives

Indications for thrombolysis in normotensive patients with pulmonary embolism (PE), based on the presence of right ventricular (RV) overload during transthoracic echocardiography (TTE), are controversial. We checked whether the monitoring of cardiac troponin T (cTnT) might help in risk stratification by detecting patients with RV myocardial injury.

Patients and design

We studied 64 normotensive patients (30 women and 34 men) with a mean (± SD) age of 61.3 ± 17 years and PE, who had undergone TTE for the assessment of RV overload. Plasma cTnT levels were measured quantitatively (detection limit, > 0.01 ng/mL) at hospital admission, and subsequently three times at 6-h intervals. Heparin therapy alone was used in 87.5% of patients, while 12.5% of patients received thrombolysis.

Results

cTnT was detected in 50% of patients. All eight in-hospital deaths occurred in the troponin-positive group, however, in one case the results of the first three assays had been negative. Elevated plasma cTnT increased the risk of PE-related death (odds ratio [OR], 21; 95% confidence interval [CI], 1.2 to 389). Increased age and elevated tricuspid regurgitant jet velocity, but not RV diameter/left ventricle diameter ratio, influenced the hospital mortality rate. Increased cTnT level was the only parameter predicting 15 in-hospital clinical adverse events (ie, death, thrombolysis, cardiopulmonary resuscitation, and IV use of catecholamine agents) [OR, 24.1; 95% CI, 2.9 to 200].

Conclusions

Patients with PE and elevated cTnT levels detected during repetitive assays are at a significant risk of a complicated clinical course and fatal outcome.

Section snippets

Clinical Data

The study analyzed normotensive patients with acute PE. PE was confirmed by typical findings from contrast-enhanced spiral CT scanning, which was performed according to the previously described protocol13in 59 cases, or by high-probability lung scintigraphy in 5 cases according to the criteria of the Prospective Investigation of Pulmonary Embolism.14At hospital admission, systemic BP was measured with a mercury sphygmomanometer, and heart rate, 12-lead ECG, and transcutaneous pulse oximetry

Clinical Data

Before entering the study, no patient was in shock or required catecholamine infusion, no patient had undergone cardiopulmonary resuscitation, or had received ventilation. At hospital admission, the mean systolic BP for the whole group was 122.3 ± 22.4 mm Hg, varying from 90 to 170 mm Hg, with a mean heart rate of 100.1 ± 19.3 L/min.

According to the results of echocardiographic examination, the study population was characterized by an enlarged RV with mean end-diastolic RV/LV ratio of 1.03 ±

Discussion

Shock or systemic hypotension with systolic BP < 90 mm Hg are generally accepted indications for urgent thrombolysis in patients with acute PE.10Although it has been reported that the in-hospital mortality rate in a subgroup of normotensive patients with signs of RV pressure overload on echocardiography may be as high as 12.6 to 15.9%,67controversies exist about whether those patients should receive thrombolysis or anticoagulation therapy alone.11Moreover, recent French retrospective study15

Conclusion

Patients with PE and detectable plasma cTnT levels on repeat assays are at significant risk for a complicated clinical course and fatal outcome. Therefore, cTnT(+) patients with PE should be regarded as a high-risk group.

References (18)

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    Elevated troponins without coronary etiology have been described in numerous studies. Elevation of Troponins were observed in 32 to 50% of patients with pulmonary thromboembolism [8], in 32 to 49% of patients with perimyocarditis [9], 52 to 55% of patients in acute heart failure [10], and 36 to 85% of patients in sepsis [11]. Elevated TnI levels have even occurred in up to 30% of heathy athletes [12].

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Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

This study was supported by grant KBN 1398/P05/2000/19 from the State Committee for Scientific Research.

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