PREDICTORS OF SHORT TERM OUTCOMES IN HIGH AND MODERATE RISK PULMONARY THROMBOEMBOLISM

Aim. To investigate on the clinical, anamnestic and laboratory-instrumental predictors of short term outcomes development in pulmonary thromboembolism (PTE).

Material and methods. To the study, 136 patients included with the high and intermediate risk PTE confirmed by multispiral computed tomography. The endpoints were obstructive shock, fatal relapse, fatal outcome, necessity of resuscitation, urgent thrombolysis and hemodynamic support. Follow-up lasted for 30 days. Patients were selected to groups of complicated (n=44) and noncomplicated (n=92) course.

Results. The predictors of adverse course of PTE were chronic heart failure of II stage (p=0,02), diabetes type 2 (p=000001), atrial fibrillation (p=0,001), permanent risk factor for PTE (p=0,002), syncope (p=0,02), positive test for the fatty acid binding cardiac protein (cFABP) (p=0,00001), troponin I positive test (p=0,02), heart rate ≥110 bpm (p=0,002), systolic BP ≤100 mmHg (p=0,00001), creatinine clearance ≤70 mL/min (p=0,0008). By the method of logistic regression a combination selected showing most predictive power, that includes heart rate ≥110 bpm, BP ≤100 mmHg, positive cFABP and diabetes. Upon the logistic regression coefficients the prediction score was formulated, named ROCky (Risk of Complications) that includes heart rate ≥110 bpm (1,5 points), BP ≤100 mmHg (2,5 pts), positive cFABP test (2 pts), diabetes type 2 (2,5 pts). The threshold estimated for prediction of combination endpoint ≥2,5 (Se 84%, Sp 75%), obstructive shock ≥3,5 (Se 83%, Sp 83%) and fatal outcome within 30 days ≥4,5 (Se 79%, Sp 82%). Combination of ≥2,5 points by ROCky and presence of echocardiographical signs of the right ventricle dysfunction showed more efficacy than the algorithm of European Society of Cardiology (2014) in the studied population of hemodynamically stable patients, for the obstructive shock, fatal relapse of PTE, fatal outcome and combination endpoint.

Conclusion. The ROCky scale has demonstrated high efficacy in prediction of complications among hemodynamically stable patients and can be recommended for further investigation and implementation into clinical practice.

1. Heit JA. The epidemiology of venous thromboembolism in the community. Arterioscler Thromb Vasc Biol 2008; 28(3):370–372.

2. Konstantinides SV, Torbicki A, Agnelli G et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. European Heart Journal 2014; 35:3033–3080 doi:10.1093/eurheartj/ehu283.

3. Lankeit M, Jimenez D, Kostrubiec M et al. Predictive value of the high-sensitivity troponin T assay and the simplified pulmonary embolism severity index in hemodynamically stable patients with acute pulmonary embolism: a prospective validation study. Circulation 2011; 124:2716–24. doi:10.1161/CIRCULATIONAHA.111.051177.

4. Jiménez D, Lobo JL, Barrios D et al. Risk stratification of patients with acute symptomatic pulmonary embolism. Intern Emerg Med 2016; 11(1):11-8. doi: 10.1007/s11739-015-1388-0.

5. Lankeit M., Dellas C, Benz V et al. The predictive value of heart-type fatty acid-binding pro-tein is independent from symptom duration in normotensive patients with pulmonary embolism. Thromb Res 2013; 132(5):543-7.

6. Bajaj A, Saleeb M, Rathor P et al. Prognostic value of troponins in acute nonmassive pulmonary embolism: A meta-analysis. Heart Lung 2015; 44(4):327-34. doi: 10.1016/j.hrtlng.2015.03.007.

7. Jiménez D, Uresandi F, Otero R et al. Troponin-based risk stratification of patients with acute nonmassive pulmonary embolism: systematic review and metaanalysis. Chest 2009; 136(4):974-82. doi: 10.1378/chest.09-0608.

8. Berghaus TM, Schwaiblmair M, von Scheidt W. Renal biomarkers and prognosis in acute pul-monary embolism. Heart 2012; 98(16):1185-6. doi: 10.1136/heartjnl-2012-302298.

9. Huang W, Goldberg RJ, Anderson FA et al. Secular trends in occurrence of acute venous thromboembolism: the Worcester VTE study (1985-2009) Am J Med 2014; 127(829–839):e825.

10. Bajaj A, Rathor P, Sehgal V et al. Prognostic Value of Biomarkers in Acute Non-massive Pul-monary Embolism: A Systematic Review and Meta-analysis. Lung 2015; 193(5):639-51. doi: 10.1007/s00408-015-9752-4.

11. Bajaj A, Rathor P, Sehgal V et al. Risk stratification in acute pulmonary embolism with heart-type fatty acid-binding protein: A meta-analysis. J Crit Care 2015; 30(5):1151.e1-7. doi: 10.1016/j.jcrc.2015.05.026.