Multimodality Assessment of Right Ventricular Strain in Patients With Acute Pulmonary Embolism

Optimal risk stratification is essential in managing patients with an acute pulmonary embolism (PE). There are limited data evaluating the potential additive value of various methods of evaluation of right ventricular (RV) strain in PE. We retrospectively evaluated RV strain by computed tomography (CT), transthoracic echocardiography (TTE), electrocardiography (ECG), and troponin levels in consecutive hospitalized patients with acute PE (May 2007 to December 2014). Four-hundred and seventy-seven patients met inclusion criteria. RV strain on ECG (odds ratio [OR] 1.9, confidence interval [CI] 1.1 to 3.3; p = 0.03), CT (OR 2.7, CI 1.5 to 4.8, p <0.001), TTE (OR 2.8, CI 1.5 to 5.4, p <0.001), or a positive troponin (OR 2.7, CI 2.0 to 6.9, p <0.001) were associated with adverse events. In patients with ECG, CT, and TTE data, increased risk was only elevated with RV strain on all 3 parameters (OR 4.6, CI 1.8 to 11.3, p <0.001). In all patients with troponin measurements, risk was only elevated with RV strain on all 3 parameters plus a positive troponin (OR 8.8, CI 2.8 to 28.1, p <0.001) and was similar in intermediate-risk PE (OR 11.1, CI 1.2 to 103.8, p = 0.04). In conclusion, in patients with an acute PE and evaluation of RV strain by ECG, CT, and TTE, risk of adverse events is only elevated when RV strain is present on all 3 modalities. Troponin further aids in discriminating high-risk patients. Multimodality assessment of RV strain is identified as a superior approach to risk assessment.