Risk assessment in acute pulmonary embolism

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Abstract
We read with great interest the paper by Aujesky et al.,1 validating the prognostic model comprising 11 routinely available clinical parameters in patients with pulmonary embolism (PE). However, the presented model is of low cost but also complex. Moreover, some parameters like presence of cancer, altered mental status, severity of heart failure, and chronic lung disease, can be difficult to assess and are observer-dependent. It is also remarkable that the presented model does not include increased creatinine level reflecting impaired renal function, which was reported to be an important prognostic factor in acute PE patients.2,3 According to the authors, this model effectively identifies patients at low risk of mortality, however, the high-risk group of fatal outcome is not unequivocally indicated. In acute PE, the medical status depends on the haemodynamic compromise mostly determined by the level of right ventricle overload. Natriuretic peptides and troponin are well-established markers of cardiovascular mortality. It is generally accepted that they reflect the severity of acute heart dysfunction in PE.4 In 2005, there were two papers that proposed including biomarkers into risk assessment. Binder et al.5 observed that NT-proBNP cut-off level of 1000 pg/mL had a high negative predictive value (95% for a complicated course, 100% for death), whereas troponin combined with echocardiography improved the prediction of outcome in intermediate-risk group. The second study also proved that low levels of NT-proBNP predict favourable outcome.3 Interestingly, mortality related to PE in patients with elevated NT-proBNP and high troponin T was similar to the death rate observed in a group of patients with clinically massive embolism and reached 33%. Importantly, both biomarkers helped to stratify 40-day prognosis in acute PE for both low and high-risk groups. Therefore, on the basis of the biomarkers model, stratifying the risk in PE seems to be the option, which provides objective and accurate prognosis assessment.

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