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Multicenter Study
. 2024 Dec 24;13(12):817-825.
doi: 10.1093/ehjacc/zuae120.

Right ventricular-pulmonary artery coupling for prognostication in acute pulmonary embolism

Mads Dam Lyhne  1   2 , Behnood Bikdeli  3   4   5   6 , David Jiménez  7   8   9 , Christopher Kabrhel  10 , David M Dudzinski  11 , Jorge Moisés  9   12 , José Luis Lobo  9   13   14 , Fernando Armestar  15 , Leticia Guirado  16 , Aitor Ballaz  17 , Manuel Monreal  9   18 ; RIETE investigators
Collaborators, Affiliations
Multicenter Study

Right ventricular-pulmonary artery coupling for prognostication in acute pulmonary embolism

Mads Dam Lyhne et al. Eur Heart J Acute Cardiovasc Care. .

Abstract

Aims: Acute pulmonary embolism (PE) increases pulmonary pressure and impair right ventricular (RV) function. Echocardiographic investigation can quantify this mismatch as the tricuspid annular plane systolic excursion (TAPSE) to pulmonary arterial systolic pressure (PASP) ratio. The aim of the study was to investigate the prognostic capabilities of TAPSE/PASP ratio in patients with acute PE.

Methods and results: We utilized the Registro Informatizado Enfermedad TromboEmbolica registry to analyse consecutive haemodynamically stable PE patients. We used multi-variable logistic regression analyses to assess the association between the TAPSE/PASP ratio and 30-day all-cause mortality across the strata of European Society of Cardiology (ESC) risk categories. We included 4478 patients, of whom 1326 (30%) had low-risk, 2425 (54%) intermediate-low risk and 727 (16%) intermediate-high risk PE. Thirty-day mortality rates were 0.7%, 2.3% and 3.4%, respectively. Mean TAPSE/PASP ratio was 0.65 ± 0.29 in low-risk patients, 0.46 ± 0.30 in intermediate-low risk and 0.33 ± 0.19 in intermediate-high risk patients. In multi-variable analyses, there was an inverse association between TAPSE/PASP ratio and 30-day mortality (adjusted OR 1.32 [95% CI 1.14-1.52] per 0.1 decrease in TAPSE/PASP). TAPSE/PASP ratio below optimal cut-points was associated with increased mortality in low- (<0.40, aOR: 5.88; 95% CI: 1.63-21.2), intermediate-low (<0.43, aOR: 2.96; 95% CI: 1.54-5.71) and intermediate-high risk patients (<0.34, aOR: 4.37; 95% CI: 1.27-15.0). TAPSE/PASP <0.44 showed net reclassification improvement of 18.2% (95% CI: 0.61-35.8) vs. RV/LV ratio >1, and 27.7% (95% CI: 10.2-45.1) vs. ESC risk strata.

Conclusion: Decreased TAPSE/PASP ratio was associated with increased mortality. The ratio may aid in clinical decision-making, particularly for intermediate-risk patients for whom the discriminatory capability of the current risk stratification tools is limited.

Keywords: Echocardiography; Pulmonary pressure; Right ventricular function; Risk stratification; TAPSE.

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Conflict of interest statement

Conflicts of interest: Dr. Monreal received unrestricted grants for research to sponsor the RIETE registry by Sanofi, Bayer, Leo and Rovi. He also participated in advisory meetings for Sanofi and BMS/Pfizer. Dr. Jimenez has no conflicts of interest related to this analysis. However, he does report serving as a speaker for BMS/Pfizer. Dr. Bikdeli is supported by a Career Development Award from the American Heart Association and VIVA Physicians (#938814) for the PE-EHR + study. Dr. Bikdeli was supported by the Scott Schoen and Nancy Adams IGNITE Award, and is supported by the Mary Ann Tynan Research Scientist award from the Mary Horrigan Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, and the Heart and Vascular Center Junior Faculty Award from Brigham and Women’s Hospital. Dr. Bikdeli reports that he was a consulting expert, on behalf of the plaintiff, for litigation related to two specific brand models of IVC filters. Dr. Bikdeli has not been involved in the litigation in 2022–2024 nor has he received any compensation in 2022–2024. Dr. Bikdeli reports that he is a member of the Medical Advisory Board for the North American Thrombosis Forum, and serves in the Data Safety and Monitory Board of the NAIL-IT trial funded by the National Heart, Lung, and Blood Institute, and Translational Sciences. Dr. Kabrhel has no conflicts of interest related to this analysis. However, he does report receiving grant funding paid to his institution from Grifols and Diagnostica Stago, as well as consulting fees from BMS/Pfizer and Abbot. The remaining authors have no conflicts of interest to declare.

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