Acute pulmonary embolism: MDCT

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Acute pulmonary embolism MDCT biomarkers

• Cecilia Becattini
• University of Perugia

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Acute pulmonary embolism MDCT biomarkers

• MDCT to diagnose PE
• MDCT for prognostic stratification
• serum biomarkers

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Acute pulmonary embolism MDCT biomarkers

• MDCT to diagnose PE
• MDCT for prognostic stratification
• serum biomarkers

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PE at MDCT
2-slice CT 1992 2 x 2.7 mm 25 sec
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Pulmonary arteries at MDCT
96 of subsegmental arteries and 54 of
sub-subsegmental arteries are identified on
multislice CT (4 rows of detectors)
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PE at MDCT
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Diagnosis of PE in stable patients
Clinical probability assessment
Low or intermediate
High ( 30)
D-dimer
Normal
Elevated
Multi-detector CT
Positive for PE
No PE
PE excluded (30)
Treat
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Diagnosis of PE in un-stable patients
Echocardiography
RVD present
No RVD
Treat stabilize
Search for alternative diagnosis
Multidetector CT
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The heart at MDCT
sagittal
coronal
4-chamber
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CT prognostic markers

• RV/LV short axis diameter ratio (gt1)
• Obstruction index
• Pulmonary artery to ascending aorta diameter
• Shape of interventricular septum

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CT prognostic markers
120 patients with acute PE 3-month f-up
Van der Meer, Radiology 2005
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e
CT prognostic markers

• A relationship was found between the shape
• of interventricular septum and RV/LV ratio
• NO significant relationship was found between the
  shape of interventricular septum and PE-related
  death
• NO significant relationship was found
• between the PA/Aao and PE-related death

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RVD at CT prognostic value

• 431 patients with acute PE

Schoepf, Circulation 2004
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RVD at CT prognostic value
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CT prognostic markers
46 pts with PE And echocardiography RV/LV
area CT ratio gt1 Se and Sp of 88 for echo RVD
Mansecal, Am J Cardiol 2005
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Multidetector CT and Short-term Outcome
PE MAP study
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Pulmonary embolism multifunctional assessment
of prognosis the PE MAP study
To evaluate the accuracy of MDCT to assess RVD
in comparison to echocardiography and serum
troponin
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Patients And Methods

• Consecutive patients were included if they had
• symptomatic acute PE diagnosed by MDCT
• echocardiography and serum troponin within 6
  hours from MDCT

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Study Outcomes

• Primary outcome
• To assess the accuracy of MDCT scan to detect RVD
  in patients with acute PE
• Secondary outcome
• To assess the prognostic value of RVD as detected
  by helical CT scan

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SPIRAL CT SCAN

• Criteria for right ventricle dysfunction
• RV / LV short-axis diameters ratio at the
  valvular plane in their maximum dimension
• Shifting of the interventicular septum
• Four or 16 slice helical CT scanners were used

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RV
LV
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SPIRAL CT SCAN

• Criteria for PE extension
• obstruction index according to the scoring system
  of Qanadli
• ? (n d)
• n number of segmental
• branches
• d obstruction degree
• (1 if partial 2 if complete)

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(No Transcript)
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Multidetector CT and Short-term Outcome
PE MAP study
See you in Florence!!
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Acute pulmonary embolism MDCT biomarkers

• MDCT to diagnose PE
• MDCT for prognostic stratification
• serum biomarkers

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Pulmonary embolism and Troponin a meta-analysis

• 20 studies included in the analysis
• n of studies
• Troponin I / T 12 / 8
• Retrospective / Prospective 4 / 16
• All patients / Stable patients 13 / 7

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Troponin and Short-term Outcome
OR CI 5.24 (3.28-8.38) 9.44
(4.14-21.49) 7.03 (2.42-20.43) 5.90
(2.68-12.95)
Death in overall population PE related
death Adverse outcome Death in stable patients
RVD more common in patients with elevated
troponin (p lt 0.05)
Becattini et al. Circulation, 2007
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BNP and Short-term Outcome
Author no. of pts Cut off Se () Sp () NPV () PPV ()
Ten Wolde 110 21.7 pmol/L 86 73 99 18
Kucher N 73 50 pg/mL NA NA 100 12
Kucher N 73 500 pg/mL NA NA 100 12
Pruszczyk P 79 600 pg/mL 100 33 100 26
Binder LN. 124 1000 pg/mL 100 49 100 10
Kostrubiec M 113 NT-proBNP gt 7500 ng/L 65 93 94 61
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BNP troponin and Short-term Outcome
100 normotensive PE patients
Cut off Se () Sp () NPV () PPV ()
NT-proBNP lt600 ng/L and cTnT lt0.07 µ/L 100 33 100 21
NT-proBNP gt600 ng/L and cTnT lt0.07 µ/L 44 40 80 11
NT-proBNP gt600 ng/L and cTnT gt0.07 µ/L 60 89 93 50
Kostrubiec, 2005
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Acute pulmonary embolism MDCT biomarkers

• MDCT to diagnose PE
• Accurate in stable and unstable patients
• MDCT for prognostic stratification
• Promising tool, wait for management studies
• serum biomarkers
• Confirmed prognostic value, ongoing management
  studies

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Acute pulmonary embolism MDCT biomarkers

• Cecilia Becattini
• University of Perugia