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Word of the Day

Normal hs troponin and PESI score of 0 means great prognosis for PE

Clinical Question:
Can we identify patients with pulmonary embolism who are at low risk of death or major complications?

Bottom Line:
Approximately 1 in 4 patients with pulmonary embolism (PE) have a high-sensitivity troponin T (hsTnT) value of less than 14 pg/mL and a Pulmonary Embolism Severity Index (PESI) score of 0. These patients are at very low risk of death or major complications at 30 days. If good compliance and follow-up can be assured, these patients may even be candidates for outpatient therapy. (LOE = 1b)

Reference:
Lankeit M, Jiménez 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(24): 2716-2724.  [PMID:22082681]

Study Design:
Cohort (prospective)

Funding:
Government

Setting:
Inpatient (any location) with outpatient follow-up

Synopsis:
It would be useful to be able to reliably identify patients with PE who are at low risk of complications and could potentially be managed entirely as outpatients. In this study, the researchers identified a consecutive series of 526 patients from 12 European centers. The protocol confirmed PE with high resolution computed tomography in all patients with high likelihood of PE based on the Wells score and in all patients with low/intermediate probability and an elevated D-dimer test result. Patients who were hemodynamically unstable were excluded. The patients' mean age was 71 years, and 22% had a history of previous PE or deep venous thrombosis. All patients underwent a systematic evaluation, including an hsTnT test and an assessment of the PESI. Of the 526 patients with PE, 198 had a low-risk PESI score of 0, and 214 had an hsTnT level of less than 14 pg/mL. All patients were followed up for 30 days to evaluate the primary end point of death or major complication (symptomatic recurrent PE, major bleeding, or cardiopulmonary resuscitation). At 30 days, 31 patients had reached this primary end point, including 27 deaths (8 of which were believed to be related to the PE). Patients with an hsTnT value of less than 14 pg/mL were less likely to reach the primary end point (1.9% vs 8.7%; P = .001), as were patients with a PESI score of 0 (1.0% vs 8.8%; P < .001). None of the 127 patients with both PESI score of 0 and an hsTnT value of less than 14 pg/mL reached the primary end point.

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