Combined risk stratification with computerized tomography /echocardiography and biomarkers in patients with normotensive pulmonary embolism

Thromb Res. 2010 Dec;126(6):486-92. doi: 10.1016/j.thromres.2010.08.021.


Background: Right ventricular dysfunction (RVD) detected by computerized tomography (CT)/echocardiography or elevated biomarkers is associated with a poor prognosis for pulmonary embolism (PE). However, these prognostic factors have not previously been concomitantly elucidated in the same patient group.

Methods: This prospective study included 108 consecutive patients with normotensive PE confirmed by CT pulmonary angiography (CTPA). On admission, patient serum NT-proBNP and troponin T (Tn-T) levels were measured, and echocardiography was performed within 24 hours after diagnosis of PE. Receiver operating characteristic (ROC) analysis was performed to determine the optimal echocardiographic end-diastolic diameters of the right ventricle, the ratio of the right ventricle to left ventricle (RV/LV ratio) on CTPA, and NT-proBNP and Tn-T cut-off levels with regard to prognosis.

Results: All-cause 30-day mortality was 13% and PE-related mortality was 5.6%. RVD was defined as a right/left ventricular dimension ratio≥1.1 on CTPA and RV>30 mm on echocardiography by ROC analysis. A cut-off level of NT-proBNP≤90 pmol/ml had a high positive predictive value of 98% for survival, whereas NT-proBNP>300 and Tn-T≥0.027 had a negative predictive value, for all-cause deaths, of 95% and 96%, respectively. PE mortality in patients with NT-proBNP>300 and Tn-T≥0.027 reached 64%. In univariable analysis, the combination of Tn-T≥0.027 ng/ml with a echocardiographic RVD were the most significant predictors of overall mortality and PE-related death [HR: 14 (95% CI: 4.6-42,) and HR: 37.6 (95% CI: 4.4-324)], respectively. In multivariable Cox's regression analysis, NT-proBNP>300 and Tn-T≥0.027 HR: 26.5 (95% CI: 4.1-169.9, p<0.001) were the best combination to predict all-cause of mortality.

Conclusions: The combination of NT-proBNP and Tn-T clearly appears to be a better risk stratification predictor than biomarkers plus RVD on CT/ echocardiography in patients with normotensive PE.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Biomarkers / analysis
  • Echocardiography
  • Female
  • Humans
  • Hypertension, Pulmonary / diagnostic imaging
  • Male
  • Middle Aged
  • Natriuretic Peptide, Brain / metabolism
  • Peptide Fragments / metabolism
  • Prognosis
  • Proportional Hazards Models
  • Prospective Studies
  • Pulmonary Embolism / blood
  • Pulmonary Embolism / diagnostic imaging*
  • Risk Factors
  • Tomography, X-Ray Computed
  • Troponin I / blood
  • Ventricular Dysfunction, Right / diagnostic imaging
  • Young Adult


  • Biomarkers
  • Peptide Fragments
  • Troponin I
  • pro-brain natriuretic peptide (1-76)
  • Natriuretic Peptide, Brain