The Impact Of Right Ventricular Dysfunction On The Clinical Outcome Of Normotensive Patients With Pulmonary Embolism

BackgroundPulmonary embolism (PE) is a common disorder and an important cause of morbidity and mortality. With regard to prognosis, patients with PE have traditionally been classified into two groups based on BP measurements at the time of presentation. But some normotensive patients with PE would become worsen, presenting with shock or death in short-term. It's an important problem how to differentiate the additional risk stratification among these patients. It has been proposed that prognosis and therapy are best defined basing echocardiographic parameters of right ventricular (RV) function in the same time. In this study, we assessed the prevalence and clinical outcome of normotensive patients with RV dysfunction among a broad of PE patient.Materials and MethodsThis retrospective study included 57 normotensive patients with pulmonary embolism.Inclusion criteria included: (1) Inpatients with confirmed PE of Sir Run Run Shaw Hospital from January 2001 to December 2004. (2) Normotensive. (3) Echocardiography done before therapy.Right ventricular dysfunction was assessed by echocardiography in the presence of ≥ 1 of the following: RV dilatation (RV/LV end diastolic diameter > 1, RV end diastolic diameter > 30mm), pulmonary hypertension (pulmonary artery systolic pressure > 30mmHg, pulmonary artery mean pressure > 20mmHg, tricuspid regurgitant velocity > 2.8 m/s).Two groups were identified: normotensive patients with RV dysfunction and normotensive patients without RV dysfunction. The clinical outcome of these two groups was analyzed.ResultsIn 68 patients, the diagnosis of PE was obtained on the basis of a high-probability lung scan, a positive CT scan, or a positive pulmonary angiography. Of the 68 patients, 57(84%) were normotensive, and echocardiography was done before therapy. So they were included in this study. 27 patients (47%)were judged to have RV dysfunction.The clinical features of normotensive patients with and without RV dysfunction are compared. There was no difference in age, gender or the prevalence of DVT, smoking, cancer or other risk factors. In the group with RV dysfunction, 5 patients (19%) died as a result of PE. In comparison, in the group without RV dysfunction, only one patient died related to bladder cancer with multiple brain metastasis and multiple cerebral infarction, none of them died directly related to PE. Echocardiography (showed RV dysfunction) showed a 100% negative predictive value for PE-related death, although its positive predictive value was very low.7 patients of the group with RV dysfunction were treated with thrombolysis, and one of them died. 20 patients treated with anticoagulation alone, 4 died. After therapy, 22 patients of this group became better, and RV dysfunction also improved in short-term.ConclusionThe mortality related to PE of normotensive patients with RV dysfunction is significantly higher than normotensive patients without RV dysfunction.In patients with PE, the echocardiography is quite usefulbecause it can often help differentiate RV dysfunction who have a significantly higher risk of death. On the other hand, we shoud guard that a patient with echocardiographic finding of acute RV dysfunction and with symptoms such as chest pain, dyspnea, hemoptysis, maybe PE.In the presence of RV dysfunction of normotensive patients with PE, the advantage of thrombolysis over anticoagulation alone has not been clearly demonstrated.After thrombolysis with/or anticoagulation, RV dysfunction of normotensive patients with PE would improve in short-term. The echocardiography would be an important means of evaluating of therapy outcome in pulmonary embolism.