Predictive value of high-sensitivity troponin I and D-dimer assays for adverse outcome in patients with acute pulmonary embolism

Walter,Thomas; Apfaltrer,Paul; Weilbacher,Frank; Meyer,Mathias; Schoenberg,Stefan  O.; Fink,Christian; Gruettner,Joachim

doi:10.3892/etm.2012.825

Predictive value of high-sensitivity troponin I and D-dimer assays for adverse outcome in patients with acute pulmonary embolism

Authors:
- Thomas Walter
- Paul Apfaltrer
- Frank Weilbacher
- Mathias Meyer
- Stefan O. Schoenberg
- Christian Fink
- Joachim Gruettner
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Affiliations: Emergency Department, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim D-68167, Germany, Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim D-68167, Germany
Published online on: November 22, 2012 https://doi.org/10.3892/etm.2012.825
Pages: 586-590

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Abstract

High-sensitivity troponin (hs-cTn) assays enable the troponin cutoff value to be lowered, resulting in an increase of sensitivity at the cost of specificity. In the present study, the risk of a short‑term adverse outcome was assessed in patients with acute pulmonary embolism (PE) using high‑sensitivity troponin I (hs-cTnI). We used a cutoff value of 0.1 ng/ml in accordance with current guidelines for unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI), although the detection limit of the troponin assay is lower. In addition, the risk of an adverse outcome in patients with acute PE was investigated with respect to initial D-dimer serum concentrations. In 65 patients with confirmed acute PE, hs-cTnI and D-dimer values were measured. Adverse clinical outcome was defined as cardiogenic shock, cardiopulmonary resuscitation, mechanical ventilation, vasopressor therapy, thrombolysis, catheter intervention or mortality within 60 days of PE. Patients with acute PE and serum hs-cTnI values >0.1 ng/ml showed significantly higher D-dimer concentrations (P=0.0467) and a 5-fold increased risk of an adverse clinical outcome [odds ratio (OR), 4.9; 95% confidence interval (CI), 1.28-18.66; P=0.0235] compared with patients with acute PE and hs-cTnI values <0.1 ng/ml. In patients with acute PE suffering from adverse clinical outcome, D-dimer concentrations were significantly elevated compared with those in patients with acute PE without adverse clinical outcome (P=0.02). In patients with acute PE, a hs-cTnI cutoff value of 0.1 ng/ml, which is identical to the recommended cutoff value of NSTEMI, may identify patients with a 5-fold increased risk of a short-term adverse outcome. D-dimer values are significantly higher in PE patients with elevated hs-cTnI values as well as in patients with an adverse outcome.

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1.	Torbicki A, Perrier A, Konstantinides S, et al: Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 29:2276–2315. 2008. View Article : Google Scholar : PubMed/NCBI
2.	Agnelli G and Becattini C: Acute pulmonary embolism. N Engl J Med. 363:266–274. 2010. View Article : Google Scholar : PubMed/NCBI
3.	Hogg K, Haslam S, Hinchliffe E, Sellar L, Lecky F and Cruickshank K: Does high-sensitivity troponin measurement aid in the diagnosis of pulmonary embolism? J Thromb Haemost. 9:410–412. 2011. View Article : Google Scholar : PubMed/NCBI
4.	Christ M, Bertsch T, Popp S, Bahrmann P, Heppner HJ and Muller C: High-sensitivity troponin assays in the evaluation of patients with acute chest pain in the emergency department. Clin Chem Lab Med. 49:1955–1963. 2011. View Article : Google Scholar : PubMed/NCBI
5.	Becattini C, Vedovati MC and Agnelli G: Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation. 116:427–433. 2007. View Article : Google Scholar : PubMed/NCBI
6.	Lankeit M, Friesen D, Aschoff J, et al: Highly sensitive troponin T assay in normotensive patients with acute pulmonary embolism. Eur Heart J. 31:1836–1844. 2010. View Article : Google Scholar : PubMed/NCBI
7.	Janata KM, Leitner JM, Holzer-Richling N, Janata A, Laggner AN and Jilma B: Troponin T predicts in-hospital and 1-year mortality in patients with pulmonary embolism. Eur Respir J. 34:1357–1363. 2009.PubMed/NCBI
8.	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. 124:2716–2724. 2011. View Article : Google Scholar
9.	Thygesen K, Mair J, Katus H, et al: Recommendations for the use of cardiac troponin measurement in acute cardiac care. Eur Heart J. 31:2197–2204. 2010. View Article : Google Scholar : PubMed/NCBI
10.	Pollack CV Jr and Braunwald E: 2007 update to the ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: implications for emergency department practice. Ann Emerg Med. 51:591–606. 2008. View Article : Google Scholar
11.	Becattini C, Lignani A, Masotti L, Forte MB and Agnelli G: D-dimer for risk stratification in patients with acute pulmonary embolism. J Thromb Thrombolysis. 33:48–57. 2012. View Article : Google Scholar : PubMed/NCBI
12.	Goldhaber SZ, Simons GR, Elliott CG, et al: Quantitative plasma D-dimer levels among patients undergoing pulmonary angiography for suspected pulmonary embolism. JAMA. 270:2819–2822. 1993. View Article : Google Scholar : PubMed/NCBI
13.	Abcarian PW, Sweet JD, Watabe JT and Yoon HC: Role of a quantitative D-dimer assay in determining the need for CT angiography of acute pulmonary embolism. AJR Am J Roentgenol. 182:1377–1381. 2004. View Article : Google Scholar : PubMed/NCBI
14.	Kabrhel C, Mark Courtney D, Camargo CA Jr, et al: Factors associated with positive D-dimer results in patients evaluated for pulmonary embolism. Acad Emerg Med. 17:589–597. 2010. View Article : Google Scholar : PubMed/NCBI
15.	Kearon C, Ginsberg JS, Douketis J, et al: An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Ann Intern Med. 144:812–821. 2006. View Article : Google Scholar : PubMed/NCBI
16.	Righini M, Perrier A, De Moerloose P and Bounameaux H: D-Dimer for venous thromboembolism diagnosis: 20 years later. J Thromb Haemost. 6:1059–1071. 2008.PubMed/NCBI
17.	Yin F, Wilson T, Della Fave A, et al: Inappropriate use of D-dimer assay and pulmonary CT angiography in the evaluation of suspected acute pulmonary embolism. Am J Med Qual. 27:74–79. 2012. View Article : Google Scholar : PubMed/NCBI
18.	Goldhaber SZ: Pulmonary embolism. Lancet. 363:1295–1305. 2004. View Article : Google Scholar : PubMed/NCBI
19.	Dunn KL, Wolf JP, Dorfman DM, Fitzpatrick P, Baker JL and Goldhaber SZ: Normal D-dimer levels in emergency department patients suspected of acute pulmonary embolism. J Am Coll Cardiol. 40:1475–1478. 2002. View Article : Google Scholar : PubMed/NCBI
20.	Gupta RT, Kakarla RK, Kirshenbaum KJ and Tapson VF: D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. AJR Am J Roentgenol. 193:425–430. 2009. View Article : Google Scholar : PubMed/NCBI
21.	Jaff MR, McMurtry MS, Archer SL, et al: Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 123:1788–1830. 2011. View Article : Google Scholar
22.	Labyk A, Ciurzynski M, Jankowski K, et al: Acute pulmonary embolism: analysis of consecutive 353 patients hospitalised in a single centre. A 3-year experience. Kardiol Pol. 70:15–22. 2012.PubMed/NCBI
23.	Horlander KT and Leeper KV: Troponin levels as a guide to treatment of pulmonary embolism. Curr Opin Pulm Med. 9:374–377. 2003. View Article : Google Scholar : PubMed/NCBI
24.	Ng AC, Yong AS, Chow V, Chung T, Freedman SB and Kritharides L: Cardiac troponin-T and the prediction of acute and long-term mortality after acute pulmonary embolism. Int J Cardiol. Aug 22–2011.(Epub ahead of print).
25.	Thygesen K, Alpert JS and White HD: Universal definition of myocardial infarction. J Am Coll Cardiol. 50:2173–2195. 2007. View Article : Google Scholar : PubMed/NCBI
26.	Alpert JS, Thygesen K, Jaffe A and White HD: The universal definition of myocardial infarction: a consensus document: ischaemic heart disease. Heart. 94:1335–1341. 2008. View Article : Google Scholar : PubMed/NCBI
27.	Wells PS, Anderson DR, Rodger M, et al: Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 83:416–420. 2000.PubMed/NCBI
28.	Le Gal G, Righini M, Roy PM, et al: Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 144:165–171. 2006.PubMed/NCBI
29.	Stein PD, Fowler SE, Goodman LR, et al: Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 354:2317–2327. 2006. View Article : Google Scholar : PubMed/NCBI
30.	van Belle A, Buller HR, Huisman MV, et al: Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 295:172–179. 2006.
31.	Perrier A, Roy PM, Sanchez O, et al: Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med. 352:1760–1768. 2005. View Article : Google Scholar : PubMed/NCBI