Advertisement

Troponin-Based Risk Stratification of Patients With Acute Nonmassive Pulmonary Embolism

Systematic Review and Metaanalysis

      Background

      Controversy exists regarding the usefulness of troponin testing for the risk stratification of patients with acute pulmonary embolism (PE). We conducted an updated systematic review and a metaanalysis of troponin-based risk stratification of normotensive patients with acute symptomatic PE. The sources of our data were publications listed in Medline and Embase from 1980 through April 2008 and a review of cited references in those publications.

      Methods

      We included all studies that estimated the relation between troponin levels and the incidence of all-cause mortality in normotensive patients with acute symptomatic PE. Two reviewers independently abstracted data and assessed study quality. From the literature search, 596 publications were screened. Nine studies that consisted of 1,366 normotensive patients with acute symptomatic PE were deemed eligible. Pooled results showed that elevated troponin levels were associated with a 4.26-fold increased odds of overall mortality (95% CI, 2.13 to 8.50; heterogeneity χ2 = 12.64; degrees of freedom = 8; p = 0.125). Summary receiver operating characteristic curve analysis showed a relationship between the sensitivity and specificity of troponin levels to predict overall mortality (Spearman rank correlation coefficient = 0.68; p = 0.046). Pooled likelihood ratios (LRs) were not extreme (negative LR, 0.59 [95% CI, 0.39 to 0.88]; positive LR, 2.26 [95% CI, 1.66 to 3.07]). The Begg rank correlation method did not detect evidence of publication bias.

      Conclusions

      The results of this metaanalysis indicate that elevated troponin levels do not adequately discern normotensive patients with acute symptomatic PE who are at high risk for death from those who are at low risk for death.
      To read this article in full you will need to make a payment
      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Goldhaber SZ
        • Visani L
        • De Rosa M
        Acute pulmonary embolism: clinical outcomes in the Cooperative Pulmonary Embolism Registry (ICOPER).
        Lancet. 1999; 353: 1386-1389
        • Becattini C
        • Agnelli G
        Risk factors for adverse short-term outcome in patients with pulmonary embolism.
        Thromb Res. 2001; : 239-244
        • Büller H
        • Agnelli G
        • Hull RD
        • et al.
        Antithrombotic therapy for venous thromboembolic disease.
        Chest. 2004; 126: 401S-428S
        • Yalamanchili K
        • Sukhija R
        • Aronow WS
        • et al.
        Prevalence of increased cardiac troponin I levels in patients with and without acute pulmonary embolism and relation of increased cardiac troponin I levels with in-hospital mortality in patients with acute pulmonary embolism.
        Am J Cardiol. 2004; 93: 263-264
        • Konstantinides S
        Pulmonary embolism: impact of right ventricular dysfunction.
        Curr Opin Cardiol. 2005; 20: 496-501
        • Konstantinides S
        • Geibel A
        • Olschewski M
        • et al.
        Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism.
        Circulation. 2002; 106: 1263-1268
        • Giannitsis E
        • Muller-Bardorff M
        • Kurowski V
        • et al.
        Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism.
        Circulation. 2000; 102: 211-217
        • Janata K
        • Holzer M
        • Laggner AN
        • et al.
        Cardiac troponin T in the severity assessment of patients with pulmonary embolism: cohort study.
        BMJ. 2003; 326: 312-313
        • Becattini C
        • Vedovati MC
        • Agnelli G
        Prognostic value of troponins in acute pulmonary embolism.
        Circulation. 2007; 116: 427-433
        • Jiménez D
        • Díaz G
        • Molina J
        • et al.
        Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism.
        Eur Respir J. 2008; 31: 847-853
        • Gallotta G
        • Palmieri V
        • Piedimonte V
        • et al.
        Increased troponin I predicts in-hospital occurrence of hemodynamic instability in patients with submassive or non-massive pulmonary embolism independent to clinical, echocardiographic and laboratory information.
        Int J Cardiol. 2008; 124: 351-357
        • Logeart D
        • Lecuyer L
        • Thabut G
        • et al.
        Biomarker-based strategy for screening right ventricular dysfunction in patients with non-massive pulmonary embolism.
        Intensive Care Med. 2007; 33: 286-292
        • Wilczynski NL
        • Haynes RB
        • Hedges Team
        Developing optimal search strategies for detecting clinically sound prognostic studies in MEDLINE: an analytic survey.
        BMC Med. 2004; 2: 23
        • Wilczynski NL
        • Haynes RB
        Optimal search strategies for detecting clinically sound prognostic studies in EMBASE: an analytic survey.
        J Am Med Inform Assoc. 2005; 12: 481-485
        • Friedenreich CM
        Methods for pooled analyses of epidemiologic studies.
        Epidemiology. 1993; 4: 295-302
        • Blair A
        • Burg J
        • Foran J
        • et al.
        Guidelines for application of meta-analysis in environmental epidemiology.
        Regul Toxicol Pharmacol. 1995; 22: 189-197
        • Downs SH
        • Black N
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of healthcare interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
        • Hayden JA
        • Côté P
        • Bombardier C
        Evaluation of the quality of prognosis studies in systematic reviews.
        Ann Intern Med. 2006; 144: 427-437
        • StataCorp
        Statistical software, version 6, 2000. Stata Corp, College Station, TX2000
        • Zamora J
        • Abraira V
        • Muriel A
        • et al.
        Meta-DiSc: a software for meta-analysis of test accuracy data.
        BMC Med Res Methodol. 2006; 6: 31
        • Hsu JT
        • Chu CM
        • Chang ST
        • et al.
        Prognostic role of right ventricular dilatation and troponin I elevation in acute pulmonary embolism.
        Int Heart J. 2006; 47: 775-781
        • Zhu L
        • Yang YH
        • Wu YF
        • et al.
        Value of transthoracic echocardiography combined with cardiac troponin I in risk stratification in acute pulmonary embolism.
        Chin Med J (Engl). 2007; 120: 17-21
        • Kucher N
        • Wallman D
        • Carone A
        • et al.
        Incremental prognostic value of troponin I and echocardiography in patients with acute pulmonary embolism.
        Eur Heart J. 2003; 24: 1651-1656
        • Mehta NJ
        • Jani K
        • Khan IA
        Clinical usefulness and prognostic value of elevated cardiac troponin I levels in acute pulmonary embolism.
        Am Heart J. 2003; 145: 821-825
        • La Vecchia L
        • Ottani F
        • Favero L
        • et al.
        Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism.
        Heart. 2004; 90: 633-637
        • Binder L
        • Pieske B
        • Olschewski M
        • et al.
        N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism.
        Circulation. 2005; 112: 1573-1579
        • Scridon T
        • Scridon C
        • Skali H
        • et al.
        Prognostic significance of troponin elevation and right ventricular enlargement in acute pulmonary embolism.
        Am J Cardiol. 2005; 96: 303-305
        • Douketis JD
        • Crowther MA
        • Stanton EB
        • et al.
        Elevated cardiac troponin levels in patients with submassive pulmonary embolism.
        Arch Intern Med. 2002; 162: 79-81
        • Meyer T
        • Binder L
        • Hruska N
        • et al.
        Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction.
        J Am Coll Cardiol. 2000; 36: 1632-1636
        • Punukollu G
        • Khan IA
        • Gowda RM
        • et al.
        Cardiac troponin I release in acute pulmonary embolism in relation to the duration of symptoms.
        Int J Cardiol. 2005; 99: 207-211
        • Masotti L
        • Antonelli F
        • Venturini E
        • et al.
        Cardiac troponin I and plasma D-dimer are related to proximal and bilateral extension of clots and right cardiac dysfunction in patients with pulmonary embolism.
        J Int Med. 2007; 262: 588-589
        • Vuilleumier N
        • Righini M
        • Perrier A
        • et al.
        Correlation between cardiac biomarkers and right ventricular enlargement on chest CT in non massive pulmonary embolism.
        Thromb Res. 2008; 121: 617-624
        • Maziere F
        • Birolleau S
        • Medimagh S
        • et al.
        Comparison of troponin I and N-terminal-pro B-type natriuretic peptide for risk stratification in patients with pulmonary embolism.
        Eur J Emerg Med. 2007; 14: 207-211
        • Aksay E
        • Yanturali S
        • Kiyan S
        Can elevated troponin I levels predict complicated clinical course and inhospital mortality in patients with acute pulmonary embolism?.
        Am J Emerg Med. 2007; 25: 138-143
        • Zhu L
        • Yang YH
        • Wu YF
        • et al.
        Value of transthoracic echocardiography combined with cardiac troponin I in risk stratification in acute pulmonary thromboembolism.
        Chin Med J (Engl). 2007; 120: 17-21
        • Pruszczyk P
        • Bochowicz A
        • Torbicki A
        • et al.
        Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism.
        Chest. 2003; 123: 1947-1952
        • Kostrubiec M
        • Pruszczyk P
        • Bochowicz A
        • et al.
        Biomarker-based assessment model in acute pulmonary embolism.
        Eur Heart J. 2005; 26: 2166-2172
        • Bova C
        • Crocco F
        • Ricchio R
        • et al.
        Importance of troponin T for the risk stratification of normotensive patients with pulmonary embolism: a prospective, cohort study with a three-month follow-up.
        Haematologica. 2005; 90: 423-424
        • Douketis JD
        • Leeuwenkamp O
        • Grobara P
        • et al.
        The incidence and prognostic significance of elevated cardiac troponins in patients with submassive pulmonary embolism.
        J Thromb Haemost. 2005; 3: 508-513
        • Kline JA
        • Hernandez-Nino J
        • Rose GA
        • et al.
        Surrogate markers for adverse outcomes in normotensive patients with pulmonary embolism.
        Crit Care Med. 2006; 34: 2773-2780
        • Tulevski II
        • ten Wolde M
        • van Veldhuisen DJ
        • et al.
        Combined utility of brain natriuretic peptide and cardiac troponin T may improve rapid triage and risk stratification in normotensive patients with pulmonary embolism.
        Int J Cardiol. 2007; 116: 161-166
        • Kucher N
        • Goldhaber S
        Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism.
        Circulation. 2003; 108: 2191-2194
        • Jiménez D
        • Yusen RD
        • Otero R
        • et al.
        Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient treatment.
        Chest. 2007; 132: 24-30

      Linked Article

      • Medical Uncertainty: Informing Decision Making for Patients With Acute Pulmonary Embolism
        CHESTVol. 136Issue 4
        • Preview
          Pulmonary embolism is a common and potentially fatal disease.1 A number of factors have been associated with a high risk of adverse short-term outcomes. These include several patient-related demographic and historical factors, such as advanced age, male sex, chronic heart failure or chronic lung disease, and malignancy.2 Patients presenting with systemic hypotension or signs of right heart failure (determined either by echocardiography or CT angiography) also have a worse prognosis.3 In addition, patients with acute PE and elevated levels of serum markers (troponin or brain natriuretic peptide), indicating myocardial injury related to right heart strain, have worse short-term survival than those with normal levels.
        • Full-Text
        • PDF