Unlocking the power of echocardiography: strategies in risk stratification of patients with PE using echocardiography

Document Type : original articles

Authors

1 Seyed-Al-Shohada cardiology Hospital, Urmia University of Medical Sciences, Urmia, Iran

2 Department of Cardiology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran

3 Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

4 Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Abstract

Objectives: Pulmonary embolism (PE) is challenging to diagnose due to nonspecific symptoms. While computed tomography pulmonary angiography (CTPA) is the gold standard, transthoracic echocardiography (TTE) is frequently used first. This study aimed to evaluate the accuracy of TTE findings in predicting the severity of CTPA-confirmed PE.
 
Methods: This retrospective study in 2023, analyzed 124 patients who underwent CTPA for suspected PE at Seyed Al Shohada Hospital of Urmia, Iran. The Pulmonary Embolism Severity Index (PESI), as a risk stratification tool for pulmonary embolism, was measured in the first hours of hospitalization. TTE was performed 48 hours following hospital admission, with an emphasis on Key TTE parameters, including McConnell’s sign, D-shape septum sign, right ventricular (RV) dimensions, left ventricular dimensions, pulmonary artery (PA) diameter, tricuspid regurgitation gradient (TRG), Tricuspid annular plane systolic excursion (TAPSE)  and PA acceleration time (PaACT). Sensitivity, specificity and predictive value were all calculated.
 
Results: Most patients were women (53.23%) over 60 (38.71%). Several TTE measures showed promise for predicting PE: RV dilation (sensitivity 84%, specificity 77%), PA diameter (84% and 28%), TRG (66% and 58%), and PA acceleration time (92% and 62%). However, McConnell’s sign had low accuracy (area under ROC curve 0.62). Tricuspid annular plane systolic excursion (TAPSE) and PA acceleration time showed the best predictive performance (AUC 0.95-0.92) and can be used as screening tools for life-threatening massive PE.PESI index test, when compared to the gold standard CT scan (which shows lung involvement), does not provide additional valuable information and accurate predictions about the severity of PE.
 
Conclusions: TAPSE and PaACT showed excellent predictive ability to CTPA-detected PE. RV dilation and PA diameter also showed good predictive capability. Findings support using some TTE indices to screen for PE severity and risk assessment before CTPA when access is limited.

Keywords

References

1.Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest.2002; 121(3):877-905.
2.Bikdeli B, Wang Y, Jimenez D, et al. Pulmonary Embolism Hospitalization,  Readmission, and Mortality Rates in US Older Adults, 1999-2015. JAMA.2019;322(6): 574-576.
3.Heit JA. Epidemiology of venous thromboembolism. Nat Rev Cardiol.2015;12(8): 464-74.
4.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(11):1573-9.
5.Moore AJE, Wachsmann J, Chamarthy MR, et al. Imaging of acute pulmonary embolism: an update. Cardiovasc Diagn Ther. 2018;8(3):225-243.
6.Pływaczewska M, Pruszczyk P, Kostrubiec M. Does kidney function matter in pulmonary thromboembolism management? Cardiol J. 2022;29(5):858-865.
7.Bĕlohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol. 2013;18(2):129-38.
8.Grant MD, Mann RD, Kristenson SD, et al. Transthoracic Echocardiography: Beginner's Guide with Emphasis on Blind Spots as Identified with CT and MRI. Radiographics. 2021;41(4):1022-1042.
9.Fields JM, Davis J, Girson L,et al. Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr.2017;30(7):714-723.e4.
10.Pradhan NM, Mullin C, Poor HD. Biomarkers and Right Ventricular Dysfunction. Crit Care Clin. 2020;36(1):141-153.
11.Schmid E, Hilberath JN, Blumenstock G, et al. Tricuspid annular plane systolic excursion (TAPSE) predicts poor outcome in patients undergoing acute pulmonary embolectomy. Heart Lung Vessel. 2015;7(2):151-158.
12.Jiménez D, Aujesky D, Moores L, et al. Simplification of the Pulmonary Embolism Severity Index for Prognostication in Patients With Acute Symptomatic Pulmonary Embolism. Arch Intern Med. 2010;170(15):1383–1389.
13.Burgos LM, Scatularo CE, Cigalini IM, et al. The addition of echocardiographic parameters to PESI risk score improves mortality prediction in patients with acute pulmonary embolism: PESI-Echo score. Eur Heart J Acute Cardiovasc Care.2021;10 (3):250-257.
14.Dahhan T, Siddiqui I, Tapson VF, et al. Clinical and echocardiographic predictors of mortality in acute pulmonary embolism. Cardiovasc Ultrasound. 2016;14(1):44.
15.Lodato JA, Ward RP, Lang RM. Echocardiographic predictors of pulmonary embolism in patients referred for helical CT. Echocardiography. 2008;25(6):584-90.
16.Turetz M, Sideris AT, Friedman OA, et al. Epidemiology, Pathophysiology, and Natural History of Pulmonary Embolism. Semin Intervent Radiol. 2018;35(2):92-98.
17.Tarbox AK, Swaroop M. Pulmonary embolism. Int J Crit Illn Inj Sci. 2013;3(1):69-72.
18.Price S, Platz E, Cullen L, et al. Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure. Nat Rev Cardiol. 2017;14(7):427-440.
19.Cash A, Minhas AMK, Pasadyn V, et al. Trends in pulmonary embolism mortality rates by age group in the United States, 1999–2019. Am Heart J Plus.2022;13: 100103.
20.Jones A, Al-Horani RA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors. Med Sci (Basel). 2023;11(3):49.
21.Martin KA, Molsberry R, Cuttica MJ, et al. Time Trends in Pulmonary Embolism Mortality Rates in the United States, 1999 to 2018. J Am Heart Assoc.2020;9(17): e016784.
22.Barco S, Valerio L, Ageno W, et al. Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000-18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database. Lancet Respir Med. 2021;9(1):33-42.
23.Katsoularis I, Fonseca-Rodríguez O, Farrington P, et al. Risks of deep vein thrombosis, pulmonary embolism, and bleeding after covid-19: nationwide self-controlled cases series and matched cohort study. BMJ. 2022;377:e069590.
24.Cires-Drouet R, LaRocco A, Soldin D, et al. Left ventricular systolic dysfunction during acute pulmonary embolism. Thromb Res. 2023;223:1-6.
25.Raymond TE, Khabbaza JE, Yadav R, et al. Significance of main pulmonary artery dilation on imaging studies. Ann Am Thorac Soc. 2014;11(10):1623-32.
26.Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med. 2002;136(9):691-700.
27.Jardin F, Dubourg O, Bourdarias JP. Echocardiographic pattern of acute cor pulmonale. Chest. 1997;111(1):209-17.
28.Vardan S, Mookherjee S, Smulyan HS, et al. Echocardiography in pulmonary embolism. Jpn Heart J. 1983;24(1):67-78.
29.Eid M, Boghdady AM, Ahmed MM, et al. Echocardiographic findings in patients with acute pulmonary embolism at Sohag University Hospitals. Egypt J Intern Med. 2022;34(1):21.
30.Bigdelu L, Daloee MH, Emadzadeh M, et al. Comparison of echocardiographic pulmonary flow Doppler markers in patients with massive or submassive acute pulmonary embolism and control group: A cross-sectional study. Health Sci Rep. 2023;6(5):e1249.
31.Rafie N, Foley DA, Ripoll JG, et al. McConnell's Sign Is Not Always Pulmonary Embolism: The Importance of Right Ventricular Ischemia. JACC Case Rep.2022;4(13): 802-807.
32.Ratanawatkul P, Oh A, Richards JC, et al. Performance of pulmonary artery dimensions measured on high-resolution computed tomography scan for identifying pulmonary hypertension. ERJ Open Res. 2020;6(1):00232-2019.
33.Vamsidhar A, Rajasekhar D, Vanajakshamma V, et al. Comparison of PESI, echocardiogram, CTPA, and NT-proBNP as risk stratification tools in patients with acute pulmonary embolism. Indian Heart J. 2017;69(1):68-74.
34.Karimialavijeh E, Khaksar A, Pishgahi G, et al. Tricuspid Annular Plane Systolic Excursion (TAPSE) Measurement by Emergency Medicine Residents in Patients Suspected of Pulmonary Emboli. J Ultrasound Med. 2022;41(8):2079-2085.
35.Alerhand S, Hickey SM. Tricuspid Annular Plane Systolic Excursion (TAPSE) for Risk Stratification and Prognostication of Patients with Pulmonary Embolism. J Emerg Med. 2020;58(3):449-456.
36.Falster C, Egholm G, Wiig R, et al. Diagnostic Accuracy of a Bespoke Multiorgan Ultrasound Approach in Suspected Pulmonary Embolism. Ultrasound Int Open. 2023;8(2):E59-e67.
37.Oh JK, Park JH. Role of echocardiography in acute Pulmonary embolism. Korean J Intern Med. 2023;38(4):456-470.
Cardiovascular Biomedicine
Volume 4, Issue 1
August 2024
Pages 10-20

Files

History

  • Receive Date: 08 April 2024
  • Revise Date: 01 August 2024
  • Accept Date: 07 August 2024

Share

How to cite

Statistics