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Risk assessment of acute pulmonary embolism utilizing coronary artery calcifications in patients that have undergone CT pulmonary angiography and transthoracic echocardiography

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A Correction to this article was published on 17 November 2020

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Abstract

Objective

To evaluate the relation of coronary artery calcifications (CAC) on non-ECG-gated CT pulmonary angiography (CTPA) with short-term mortality in patients with acute pulmonary embolism (PE).

Methods

We retrospectively included all in-patients between May 2007 and December 2014 with an ICD-9 code for acute PE and CTPA and transthoracic echocardiography available. CAC was qualitatively graded as absent, mild, moderate, or severe. Relations of CAC with overall and PE-related 30-day mortality were assessed using logistic regression analyses. The independence of those relations was assessed using a nested approach, first adjusting for age and gender, then for RV strain, peak troponin T, and cardiovascular risk factors for an overall model.

Results

Four hundred seventy-nine patients were included (63 ± 16 years, 52.8% women, 47.2% men). In total, 253 (52.8%) had CAC—mild: 143 (29.9%); moderate: 89 (18.6%); severe: 21 (4.4%). Overall mortality was 8.8% (n = 42) with higher mortality with any CAC (12.6% vs. 4.4% without; odds ratio [OR] 3.1 [95%CI 2.1–14.5]; p = 0.002). Mortality with severe (19.0%; OR 5.1 [95%CI 1.4–17.9]; p = 0.011), moderate (11.2%; OR 2.7 [95%CI 1.1–6.8]; p = 0.031), and mild CAC (12.6%; OR 3.1 [95%CI 1.4–6.9]; p = 0.006) was higher than without. OR adjusted for age and gender was 2.7 (95%CI 1.0–7.1; p = 0.050) and 2.6 (95%CI 0.9–7.1; p = 0.069) for the overall model. PE-related mortality was 4.0% (n = 19) with higher mortality with any CAC (5.9% vs. 1.8% without; OR 3.5 [95%CI 1.1–10.7]; p = 0.028). PE-related mortality with severe CAC was 9.5% (OR 5.8 [95%CI 1.0–34.0]; p = 0.049), with moderate CAC 6.7% (OR 4.0 [95%CI 1.1–14.6]; p = 0.033), and with mild 4.9% (OR 2.9 [95%CI 0.8–9.9]; p = 0.099). OR adjusted for age and gender was 4.2 (95%CI 0.9–20.7; p = 0.074) and 3.4 (95%CI 0.7–17.4; p = 0.141) for the overall model. Patients with sub-massive PE showed similar results.

Conclusion

CAC is frequent in acute PE patients and associated with short-term mortality. Visual assessment of CAC may serve as an easy, readily available tool for early risk stratification in those patients.

Key Points

• Coronary artery calcification assessed on computed tomography pulmonary angiography is frequent in patients with acute pulmonary embolism.

• Coronary artery calcification assessed on computed tomography pulmonary angiography is associated with 30-day overall and PE-related mortality in patients with acute pulmonary embolism.

• Coronary artery calcification assessed on computed tomography pulmonary angiography may serve as an additional, easy readily available tool for early risk stratification in those patients.

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Abbreviations

CAC:

Coronary artery calcification

CI:

Confidence interval

CTPA:

Computed tomography pulmonary angiography

ICD:

International classification for disease

NT-proBNP:

N-terminal prohormone of brain natriuretic peptide

OR:

Odds ratio

PACS:

Picture archiving and communication system

PE:

Pulmonary embolism

RV:

Right ventricle/right ventricular

RV/LV:

Right to left ventricular ratio

TAPSE:

Tricuspid annular plane systolic excursion

TTE:

Transthoracic echocardiography

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Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA

    Benedikt H. Heidinger, Rachael R. Kirkbride, Warren J. Manning & Diana E. Litmanovich

  2. Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria

    Benedikt H. Heidinger

  3. Cardiothoracic Radiology, Department of Radiology, Queen’s University, Kingston, Ontario, Canada

    Dominique DaBreo

  4. Cardiology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal

    Mario Santos

  5. Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Brett J. Carroll, Donya Mohebali, Ian McCormick, Jason D. Matos & Warren J. Manning

  6. Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Brett J. Carroll, Donya Mohebali, Ian McCormick, Jason D. Matos & Warren J. Manning

  7. Department of Medicine (Section of Cardiovascular Medicine), Boston University School of Medicine, Boston Medical Center, Boston, MA, USA

    Stephanie A. Feldman

Authors
  1. Benedikt H. Heidinger
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  2. Dominique DaBreo
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  4. Mario Santos
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  5. Brett J. Carroll
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  7. Donya Mohebali
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  11. Diana E. Litmanovich
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Corresponding author

Correspondence to Diana E. Litmanovich.

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Guarantor

The scientific guarantor of this publication is Diana Litmanovich.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Some study subjects or cohorts have been previously reported in:

1. Carroll BJ, Heidinger BH, Dabreo DC et al (2018) Multimodality assessment of right ventricular strain in patients with acute pulmonary embolism. Am J Cardiol 122:175-181

2. Mohebali D, Heidinger BH, Feldman SA et al (2019) Right ventricular strain in patients with pulmonary embolism and syncope. J Thromb Thrombolysis. 10.1007/s11239-019-01976-w

3. Matos JD, Heidinger BH, Dabreo DC et al (2020, in press) Mitral annular plane systolic excursion and tricuspid annular plane systolic excursion for risk stratification of acute pulmonary embolism. Echocardiography

Methodology

• retrospective

• observational

• performed at one institution

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The original online version of this article was revised: The spelling of Rachael R. Kirkbride’s name was incorrect.

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Heidinger, B.H., DaBreo, D., Kirkbride, R.R. et al. Risk assessment of acute pulmonary embolism utilizing coronary artery calcifications in patients that have undergone CT pulmonary angiography and transthoracic echocardiography. Eur Radiol 31, 2809–2818 (2021). https://doi.org/10.1007/s00330-020-07385-5

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  • DOI: https://doi.org/10.1007/s00330-020-07385-5

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