Decision for aggressive therapy in acute pulmonary embolism: implication of elevated troponin T
Felix Post1, Dirk Mertens, Christoph Sinning
1Second Medical Clinic, Johannes Gutenberg-University, Mainz, Germany. post@2-med.klinik.uni-mainz.de
Insights
Elevated cardiac troponin T (cTnT) in pulmonary embolism (PE) patients indicates higher mortality risk. For intermediate-risk PE patients without elevated cTnT, anticoagulation alone is a safe and effective treatment strategy.
Area of Science:
- Cardiology
- Pulmonary Medicine
- Biomarkers
Background:
- Elevated cardiac troponin T (cTnT) in acute pulmonary embolism (PE) lacks therapeutic implication.
- Institutional protocol uses cTnT elevation to guide first-line fibrinolytic therapy in PE.
- Study aimed to assess the safety of this cTnT-guided regimen regarding 30-day outcomes.
Purpose of the Study:
- Evaluate the safety of a cTnT-guided therapeutic strategy in acute pulmonary embolism.
- Determine if elevated cTnT predicts adverse outcomes in PE patients.
- Assess the efficacy of anticoagulation alone versus thrombolysis in intermediate-risk PE.
Main Methods:
- Retrospective analysis of 192 consecutive PE patients (2000-2005).
- Echocardiography for right ventricular function, cTnT levels on admission.
- Treatment stratified by cTnT levels: anticoagulation alone vs. physician-discretion thrombolysis.
Main Results:
- cTnT elevation was associated with significantly higher 30-day mortality (P=0.009).
- Intermediate-risk PE patients with negative cTnT had low 30-day mortality (1.8%) with anticoagulation alone.
- Intermediate-risk PE patients with elevated cTnT showed a markedly higher mortality rate (20.8%, P<0.001).
Conclusions:
- Anticoagulation alone is a safe and effective strategy for intermediate-risk PE patients without elevated cTnT.
- These patients demonstrate midterm prognoses comparable to low-risk PE patients.
- A conservative treatment approach based on cTnT levels did not result in unfavorable outcomes.
Background:
Elevated cardiac troponin T (cTnT) has been described in the setting of acute pulmonary embolism (PE) earlier, though currently it has no implication on the therapy in this setting. The protocol established in our institution recommends the use of fibrinolytic therapy as first-line therapy in these patients only when cTnT is elevated. This analysis was performed to evaluate the safety of this regimen in regard to 30-day mortality, morbidity and complications.
Methods And Results:
A total of 192 consecutive patients with confirmed PE, presenting at our institution during 2000-2005, were recruited. Right ventricular function was determined echocardiographically. CTnT was determined in all patients on admission. Patients without elevated cTnT were treated with anticoagulation alone, while patients with a TnT level above 0.1 ng/mL PE could be treated with thrombolysis on the discretion of the physician in charge. On day 30, cTnT elevation was associated with a higher mortality (P = 0.009). Moreover, in patients with intermediate-risk PE that were cTnT negative anticoagulation alone was safe showing a 30-day mortality of 1.8%, similar to low-risk PE (2.0%). In contrast to this patients with intermediate-risk PE with cTnT elevation showed a mortality rate of 20.8%, which was significantly higher (P < 0.001).
Conclusions:
In patients with intermediate-risk PE without elevated cTnT, anticoagulation alone seems to be a safe regimen. The midterm prognosis of these patients is as good as the prognosis of patients with low-risk PE. In this cohort of patients with PE, beginning with a more conservative treatment strategy per se did not lead to an unfavourable outcome.
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