Published ahead of print on November 12, 2009, doi:10.1164/rccm.200906-0970OC Am. J. Respir. Crit. Care Med., Volume 181, Number 2, January 2010, 168-173 A more recent version of this article appeared on January 15, 2010
Submitted on June 27, 2009 Prognostic Factors for Pulmonary Embolism: The PREP Study, A Prospective Multicenter Cohort StudyOlivier Sanchez1*,1 Assistance Publique Hopitaux de Paris, Hopital Europeen Geroges Pompidou, Service de Pneumologie et Soins Intensifs, Universite Paris Descartes, Paris, France, 2 Assistance Publique Hopitaux de Paris, Hopital Europeen Georges Pompidou, Unite de Recherche Clinique, INSERM CIE 4, Universite Paris Descartes, Paris, France, 3 Service de Reanimation Medicale, Assistance Publique Hopitaux de Paris, Hopital Ambroise Pare, Boulogne, France, 4 Service de Pneumologie, Hôpital La Cavale Blanche, Brest, France, 5 Service de Cardiologie A, Hôpital Trousseau, Tours, France, 6 Service de Cardiologie, CHU Jean Minjoz, Besançon, France, 7 Acute Medicine Department, Accidents and Emergency Unit, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium, 8 Service d’accueil des urgences, CHU d’Angers, Angers, France, 9 Service de Pneumologie, Assistance Publique Hopitaux de Paris, Hopital Antoine Beclere, Clamart, France, 10 Division of General Internal Medicine, Geneva University Hospital, Geneva, Switzerland, 11 Service de Pneumologie, Assistance Publique Hopitaux de Paris, Hotel Dieu de Paris, Paris, France, 12 Service des Urgences et Reanimation Medicale, CHU St-Etienne Bellevue, St-Etienne, France, 13 Service de Biochimie, Assistance Publique Hopitaux, Hopital Europeen Georges Pompidou, Paris, France * To whom correspondence should be addressed. E-mail: olivier.sanchez{at}egp.aphp.fr.
Rationale: The short-term prognosis of pulmonary embolism (PE) depends on hemodynamic status and underlying disease. The prognostic value of right ventricular dysfunction and injury is less well established. Objectives: To evaluate prognostic factors of PE in a multicenter prospective cohort study. Methods: Echocardiography, brain natriuretic peptide (BNP), N-terminal-proBNP and cardiac troponin I measurements were done on admission of 570 consecutive patients with an acute PE. A predictive model was based on independent predictors of thirty-day adverse events defined as death, secondary cardiogenic shock or recurrent venous thromboembolism. Measurements and main results: At 30 days, 42 patients (7.4%; 95% confidence interval (CI), 5.5% to 9.8%) had adverse events. On multivariate analysis, altered mental state (OR 6.8; 95% CI, 2.0 to 23.3), shock on admission (OR 2.8; 95% CI, 1.1 to 7.5), cancer (OR 2.9; 95% CI, 1.2 to 6.9), BNP (OR 1.3 for an increase of 250 ng/L; 95% CI, 1.1 to 1.6) and right to left ventricle diameter ratio (OR 1.2 for an increase of 0.1; 95% CI, 1.1 to 1.4) were associated with 30-day adverse events. The predictive performance of the model was good (area under receiver operating characteristics curve 0.84 (95% CI, 0.78 to 0.90)), making it possible to develop a bedside prognostic score. Conclusion: BNP and echocardiography may be useful determinants of the short-term outcome for patients with PE, together with clinical findings. PE patients can be stratified according to the initial risk of adverse outcome, using a simple score based on clinical, echocardiographic and biochemical variables. Key words: pulmonary embolism • prognosis • natriuretic peptides • echocardiography
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