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Echocardiographic predictors of mortality in intermediate-risk pulmonary embolism

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Abstract

Data regarding further risk stratification of intermediate-risk pulmonary embolism (IR-PE) are scanty. Whether transthoracic echocardiography may be helpful in further risk assessment of death in such population has still to be proven. Two-hundred fifty-four consecutive patients (51.6% females, age 63.7 ± 17.3 years) with IR-PE admitted to a tertiary regional referral center were enrolled. Patients underwent a complete transthoracic echocardiography within 36 h from hospital admission, on top of clinical assessment, physical examination, computer tomography pulmonary angiography (CTPA), and serum measurement of Troponin I (TnI) levels. The occurrence of 90 day mortality was chosen as primary outcome measure. When compared to survivors, non-surviving IR-PE patients had smaller left-ventricular end-diastolic volumes (39.8 ± 20.9 vs 49.4 ± 19.9 ml/m2, p = 0.006) with reduced stroke volume index (SVi) (24.7 ± 10.9 vs 30.9 ± 12.6 ml/m2, p: 0.004) and time–velocity integral at left-ventricular outflow tract (VTILVOT) (0.17 ± 0.03 vs 0.20 ± 0.04 m, p = 0.0001), whereas no differences were recorded regarding right heart parameters. Cox regression analysis revealed that right atrial enlargement (RAE) (HR 3.432, 5–95% CI 1.193–9.876, p: 0.022), the ratio between tricuspid annulus plane excursion and pulmonary arterial systolic pressure (TAPSE/PASp) (HR 4.833, 5–95% 1.230–18.986, p = 0.024), as well as SVi (HR 11.199, 5–95% CI 2.697–48.096, p = 0.001) and VTILVOT (HR 4.212, 5–95% CI 1.384–12.820, p = 0.011) were powerful independent predictors of mortality. Neither CTPA RV/LV nor TnI resulted associated with impaired survival. In intermediate-risk pulmonary embolism, RAE, TAPSE/PASp ratio, SVi, and VTILVOT predict independently prognosis to a greater extent than CTPA and TnI.

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Availability of data and materials

The data that support the findings of this study are available from the corresponding author, LF, upon reasonable request.

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Acknowledgements

This paper is dedicated to the memory of Prof. Maurizio Galderisi, whose passion and commitment to research have been inspiring young fellows, who had the privilege of being in contact with him.

Funding

Dr. D’Agostino’s contribution was supported by the Italian Ministry of Health under grant: GR-2016-02364727 “Choosing Wisely” in Pulmonary Arterial Hypertension: redefining current screening, follow-up, and prognostic procedures in patients with Pulmonary Arterial Hypertension.

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Author notes

  1. Lorenzo Falsetti and Alberto M. Marra have equally contributed to this paper.

Authors and Affiliations

  1. Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, Via Conca 71, Ancona, Italy

    Lorenzo Falsetti, Vincenzo Zaccone, Tamira Gentili, Cinzia Nitti & Aldo Salvi

  2. Department of Translational Medical Sciences, “Federico II” University Hospital and School of Medicine, Naples, Italy

    Alberto Maria Marra & Antonio. Cittadini

  3. Center for Pulmonary Hypertension, Thoraxclinic at Heidelberg University Hospital, Heidelberg, Germany

    Alberto Maria Marra

  4. Emergency Medicine Residency Program, Marche Polytechnic University, Ancona, Italy

    Mattia Sampaolesi, Francesca Riccomi, Laura Giovenali & Emanuele Guerrieri

  5. Clinica di Neurologia, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, Ancona, Italy

    Giovanna Viticchi

  6. IRCCS SDN, Naples, Italy

    Anna D’Agostino

  7. Clinica Medica, Azienda Ospedaliero-Universitaria “Ospedali Riuniti” di Ancona, Ancona, Italy

    Gianluca Moroncini

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Contributions

LF, AMM, VZ, and SM made a substantial contribution to the conception, design of the work, to the analysis, and interpretation of the data, drafted the work, and revised it; FR, LG, EG, VG, and ADG made a substantial contribution to the conception of the work, to the interpretation of the data, and revised the work; NC and TG made a substantial contribution to the analysis and interpretation of the data, drafted the work, and revised it; GM, AC, and AS made a substantial contribution to the conception, design, supervision, and revision of the work. All authors have read and agreed to the submitted version of the manuscript.

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Correspondence to Lorenzo Falsetti.

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The study was approved by the local Ethical Committee (Comitato Etico Regione Marche, Protocol n. 217/2020).

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Comitato Etico Regione Marche, Protocol n. 217/2020) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Falsetti, L., Marra, A.M., Zaccone, V. et al. Echocardiographic predictors of mortality in intermediate-risk pulmonary embolism. Intern Emerg Med 17, 1287–1299 (2022). https://doi.org/10.1007/s11739-021-02910-w

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