Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis

Eur Heart J. 2019 Mar 14;40(11):902-910. doi: 10.1093/eurheartj/ehy873.


Aims: Patients with acute pulmonary embolism (PE) classified as low risk by the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI), or the Hestia criteria may be considered for early discharge. We investigated whether the presence of right ventricular (RV) dysfunction may aggravate the early prognosis of these patients.

Methods and results: We did a systematic review and meta-analysis of studies including low-risk patients with acute PE to investigate the prognostic value of RV dysfunction. Diagnosis of RV dysfunction was based on echocardiography or computed tomography pulmonary angiography. In addition, we investigated the prognostic value of elevated troponin or natriuretic peptide levels. The primary outcome was all-cause mortality at 30 days or during hospitalization. We included 22 studies (N = 3295 low-risk patients) in the systematic review: 21 were selected for quantitative analysis. Early all-cause mortality rates in patients with vs. without RV dysfunction on imaging were 1.8% [95% confidence interval (CI) 0.9-3.5%] vs. 0.2% (95% CI 0.03-1.7%), respectively, [odds ratio (OR) 4.19, 95% CI 1.39-12.58]. For troponins, rates were 3.8% (95% CI 2.1-6.8%) vs. 0.5% (95% CI 0.2-1.3%), (OR 6.25, 95% CI 1.95-20.05). For natriuretic peptides, only data on early PE-related mortality were available: rates were 1.7% (95% CI 0.4-6.9%) vs. 0.4% (95% CI 0.1-1.1%), (OR 3.71, 95% CI 0.81-17.02).

Conclusions: In low-risk patients with acute PE, the presence of RV dysfunction on admission was associated with early mortality. Our results may have implications for the management of patients who appear at low risk based on clinical criteria alone, but present with RV dysfunction as indicated by imaging findings or laboratory markers.

Keywords: Anticoagulation; Home treatment; Mortality; Pulmonary embolism; Right ventricular dysfunction; Risk stratification.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Systematic Review

MeSH terms

  • Acute Disease
  • Adult
  • Aged
  • Aged, 80 and over
  • Anticoagulants / therapeutic use
  • Biomarkers / blood*
  • Computed Tomography Angiography / methods
  • Echocardiography / methods
  • Female
  • Hospital Mortality
  • Humans
  • Male
  • Middle Aged
  • Natriuretic Peptides / blood
  • Prognosis
  • Pulmonary Embolism / diagnosis*
  • Pulmonary Embolism / drug therapy
  • Risk Assessment / methods
  • Severity of Illness Index
  • Troponin / blood
  • Ventricular Dysfunction, Right / blood
  • Ventricular Dysfunction, Right / complications*
  • Ventricular Dysfunction, Right / diagnostic imaging
  • Ventricular Dysfunction, Right / physiopathology*


  • Anticoagulants
  • Biomarkers
  • Natriuretic Peptides
  • Troponin