Inconsistencies in the Use of Cardiac Biomarkers or Echocardiography in Patients with Acute Non-Massive Pulmonary Embolism

Transcription

1 Inconsistencies in the Use of Cardiac Biomarkers or Echocardiography in Patients with Acute Non-Massive Pulmonary Embolism The Swiss Venous Thromboembolism Registry (SWIVTER) Nils Kucher University Hospital Bern, Switzerland

2 Disclosure of Interest SWIVTER was sponsored by Sanofi Aventis, Switzerland Dr. Kucher received research grants from Sanofi-Aventis, GSK, BMS, Pfizer and Bayer Dr. Kucher is consultant to EKOS Corporation and Bayer Dr. Kucher received speaker honoraria from Sanofi-Aventis, Bayer, GSK, BMS, Boehringer Ingelheim, and Pfizer

3 ESC 2008 PE Guidelines (I) Recommendation: Evaluation of hemodynamic status, signs of right ventricular dysfunction and myocardial injury and the assessment of additional patient-related factors are useful for optimal risk stratification. Recommendation: In patients with non-high-risk PE, further stratification to an intermediate or low-risk-pe subgroup based on the presence of imaging or biochemical markers of right ventricular dysfunction and myocardial injury should be considered (Grade IIa B). Eur Heart J 2008: 29:

4 ESC 2008 PE Guidelines (II) Recommendation: Routine use of thrombolysis (or embolectomy) in non-high-risk PE patients is not recommended, but it may be considered in selected patients with intermediate-risk PE (Grade IIb B). Eur Heart J 2008: 29:

5 SWIVTER Risk Stratification: Aim To investigate the use of cardiac biomarkers and echocardiography for assessing right ventricular function for risk stratification in patients with acute non-massive pulmonary embolism (PE) and its effect on the management in daily clinical practice.

6 SWIVTER Risk Stratification: Methods 587 patients with acute objectively confirmed non-massive PE from 18 hospitals were enrolled between January 2009 and May 2010 Cardiac risk stratification was defined as availability of a troponin test or an echocardiogram for the evaluation of RV function within 24 hours of PE diagnosis

7 SWIVTER Risk Stratification: Results 178 (30%) neither had a biomarker test nor an echocardiographic evaluation 196 (34%) had a biomarker test only 47 (8%) had an echocardiogram only 166 (28%) had both tests Among the 409 (70%) patients with cardiac risk stratification (biomarkers OR echocardiography) 210 (51%) had at least one positive test 67 (16%) had positive biomarkers and right ventricular dysfunction

8 SWIVTER Risk Stratification: Demographics & Comorbidities Demographics Total N = 587 Cardiac Risk Stratification N = 409 No Cardiac Risk Stratification N = 178 Age, mean years SD 65 ± ± ± 18 <0.001 Women, n (%) 273 (46.5) 198 (48.4) 75 (42.1) 0.16 Inpatient at the time of diagnosis, n (%) 301 (48.7) 188 (54.0) 113 (36.5) <0.001 Comorbidities Cancer, n (%) 149 (25.4) 92 (22.5) 57 (32.0) Prior thromboembolism, n (%) 143 (24.4) 98 (24.0) 45 (25.3) 0.73 Bed rest for >3 days within 30 days, n (%) 99 (16.9) 60 (14.7) 39 (21.9) Obesity, n (%) 84 (14.3) 64 (15.7) 20 (11.2) 0.16 Surgery within 30 days, n (%) 74 (12.6) 49 (12.0) 25 (14.0) 0.49 P

9 SWIVTER Risk Stratification: Clinical Severity Clinical findings Total N = 587 Cardiac Risk Stratification N = 409 No Cardiac Risk Stratification N = 178 Dyspnea, n (%) 483/584 (82.7) 351/408 (86.0) 132/176 (75.0) Right heart strain on ECG, n (%) 204/448 (45.5) 177/363 (48.8) 27/85 (31.8) Provoked PE, n (%) 218 (37.1) 138 (33.7) 80 (44.9) Thrombosis of main stem or main pulmonary arteries, n (%) 197 (33.6) 151 (36.9) 46 (25.8) Oxygen saturation in room air <90%, n (%) 146/526 (27.8) 112/364 (30.8) 34/162 (21.0) Heart rate 110 beats/min, n (%) 130/563 (23.1) 107/396 (27.0) 23/167 (13.8) Syncope, n (%) 44/584 (7.5) 40/408 (9.8) 4/176 (2.3) Increased spesi, n (%) 390 (66.4) 285 (69.7) 105 (59.0) P

10 SWIVTER Risk Stratification: Treatment Total N = 587 Cardiac Risk Stratification N = 409 No Cardiac Risk Stratification N = 178 P Inpatient therapy, n (%) 524 (89.3) 381 (93.2) 143 (80.3) <0.001 ICU admission, n (%) 32 (5.5) 23 (5.6) 9 (5.1) 0.78 Reperfusion therapy*, n (%) 25 (4.3) 20 (4.9) 5 (2.8) 0.25 Systemic thrombolysis, n (%) 13 (2.2) 13 (3.2) 0 (0.0) Catheter therapy, n (%) 8 (1.4) 6 (1.5) 2 (1.1) 0.74 Surgical thrombectomy, n (%) 7 (1.2) 4 (1.0) 3 (1.7) 0.47 Inferior vena cava filter, n (%) 14 (2.4) 10 (2.4) 4 (2.3) 0.89 *some patients had a combination of systemic thrombolysis, catheter therapy, or surgical thrombectomy

11 SWIVTER Risk Stratification: Risk Stratification Details and Reperfusion Therapy

12 SWIVTER Risk Stratification: Clinical factors associated with absent testing of cardiac risk Analysis Univariate Multivariate Factor OR 95% CI P OR 95% CI P Outpatient at the time of PE diagnosis < <0.001 Cancer Provoked PE Age, per year < <0.001 Heart rate 110 beats/min Syncope

13 SWIVTER Risk Stratification: Conclusions (I) Although elderly patients and those with clinically severe PE were more likely to receive a biomarker test or an echocardiogram, these tools were used inconsistently and rarely in combination. With such lack of systematic use, it is not surprising that testing of cardiac risk had little effect on the management.

14 SWIVTER Risk Stratification: Conclusions (II) The ESC guidelines provide no strong recommendations on how exactly cardiac risk stratification should be performed. It remains unclear if non-high-risk patients should have: one test (biomarkers OR echo), or conditinal testing, i.e., biomakers followed by echo in biomarker-positive patients, or routine combined testing (biomarker + echo). It also remains debatable if cardiac risk stratification should routinely be recommended from guidelines without class I evidence on the benefit of reperfusion therapy in intermediate-risk patients.