The Joint Detection Of D-dimer Combined With N-Terminal Pro-Brain Natriuretic Peptide And Cardiac Troponin I And The Prognosis Of Acute Pulmonary Embolism: A Longitudinal Study

Objectives To explore the predictive value of d-dimer,N-Terminal Pro-Brain Natriuretic Peptide and troponin I for the prognosis of acute pulmonary embolism,so as to provide some clues for the prognosis assessment of acute pulmonary embolism.Methods The medical records of 259 consecutive patients who were aged over eighteen years old and firstly confirmed acute pulmonary embolism in the Affiliated Hospital of North China of University of Science and Technology,Tangshan Gongren Hospital and Kailuan General Hospital from January 1,2011 to December 31,2015 were retrospectively collected.The diagnostic criteria was in accordance with the Guidelines on the diagnosis and management of acute pulmonary embolism issued by the European heart association in 2008.The general situation,clinical symptoms and signs,arterial blood gas index,imaging examination,treatment,concomitant disease,biochemical markers(D-dimer,N-Terminal Pro-Brain Natriuretic Peptide and troponin I)of all the patients included in the study were collected.And all the patients included underwent followed up,and the ending point was defined as all-cause death.The outcome event is defined as all-cause death or acute pulmonary embolism recurrence.According to whether the patients experienced the outcome event,patients were divided into two groups: poor prognosis group and good prognosis group.Use the Epidata3.1 software for data entry and SAS 9.3 software and Med Calc 15.2.2 version software for statistical analysis.The Kaplan-Meier cumulative survival rate curve was drawed,and use the log-rank test to compare the survival curves.After adjustment of the covariates,including age,gender,pulse rate,heart rate,systolic blood pressure,smoking,alcohol drinking,mental state changes,arterial oxyhaemoglobin saturation,cancer,chronic cardiopulmonary disease,treatment,medication adherence and hospital,the Cox proportional hazards regression model analysis was to analyze the significance of d-dimer,N-Terminal Pro-Brain Natriuretic Peptide and troponin I for the prognosis of acute pulmonary embolism patients.Use the receiver-operating characteristic curve(ROC)to evaluate the accuracy of the d-dimer,N-Terminal Pro-Brain Natriuretic Peptide and troponin I predicting the prognosis of acute pulmonary embolism,and calculate the sensitivity,specificity,positive predictive value,negative predictive value,positive likelihood ratio,negative likelihood ratio and the area under the curve.Use the Hanley and Mc Neil method to compare the area under the receiver-operating characteristic curve.Results 1 A total of 259 cases of acute pulmonary embolism patients were enrolled in the analysis including 132 cases of male,127 cases of female.Levels of d-dimer,N-Terminal Pro-Brain Natriuretic Peptide and troponin I were all normal in 7 cases.Only one of three indicators was abnormal in 67 cases.Two of three indicators were abnormal in 117 cases.Three indicators were abnormal in 68 cases.After the follow-up of study,a total of 78 patients had poor prognosis.Among them,37 cases died and 41 cases had recurrence of acute pulmonary embolism.2 The incidence of poor prognosis was all higher with single,two or three abnormal biomarkers.The different numbers of abnormality would lead to a statistically different prognosis in patients with acute pulmonary embolism(P=0.00).The incidence of poor prognosis of three abnormalities was higher than that of single abnormal biomarker and two abnormal biomarkers.There was no statistically significance between single abnormal biomarker and two abnormal biomarkers.3 The median survival time of 259 cases of acute pulmonary embolism was 45.57 months.Compared with no abnormal biomarkers,the survival rate of people who had single,two or three abnormal biomarkers was lower(the log rank test,all P<0.05).And the median survival period was shortened.4 After adjustment of the covariates,including age,gender,pulse rate,heart rate,systolic blood pressure,smoking,alcohol drinking,mental state changes,arterial oxyhaemoglobin saturation,cancer,chronic cardiopulmonary disease,treatment,medication adherence and hospital,the Cox regression model demonstrated that the risk of poor prognosis for three abnormal biomarkers was higher than single and two abnormal biomarkers.The hazard ratio(95% confidence interval)was 11.29(4.31-4.31),6.40(3.28-12.50),respectively.However,compared with single abnormal biomarker,the risk of poor prognosis for two abnormal biomarkers lead to no statistical significance.The single abnormal N-Terminal Pro-Brain Natriuretic Peptide,single abnormal troponin I,combination of d-dimer and NTerminal Pro-Brain Natriuretic Peptide,combination of d-dimer and troponin I,combination of N-Terminal Pro-Brain Natriuretic Peptide and troponin I,and combination of d-dimer and N-Terminal Pro-Brain Natriuretic Peptide and troponin I would increase risk of poor prognosis in patients with acute pulmonary embolism.The hazard ratio(95% confidence interval)was 6.17(3.12-12.19),2.74(1.45-5.16),7.90(4.00-15.61),2.99(1.60-5.58),6.06(3.37-10.89),7.71(4.23-14.06),respectively.5 The ROC curve analysis showed that the sensitivity and specificity of combination of three biomarkers evaluating the prognosis of patients with acute pulmonary embolism were 0.64,0.90,respectively.And the area under the curve was bigger than single biomarker,combination of d-dimer and NTerminal Pro-Brain Natriuretic Peptide,combination of N-Terminal Pro-Brain Natriuretic Peptide and troponin I.Second,the sensitivity and specificity of combination of d-dimer and troponin I evaluating the prognosis of patients with acute pulmonary embolism were 0.73,0.65,respectively.And the area under the curve was bigger than single biomarkers.The sensitivity and specificity of combination of N-Terminal Pro-Brain Natriuretic Peptide and troponin I evaluating the prognosis of patients with acute pulmonary embolism were 0.64,0.88,respectively.And the area under the curve was bigger than single N-Terminal Pro-Brain Natriuretic Peptide and single troponin I.Conclusions 1 The recurrence or all-cause death risk would increase in acute pulmonary embolism patients who had combination of abnormal d-dimer,N-Terminal Pro-Brain Natriuretic Peptide and troponin I.2 The combination detection of d-dimer,N-Terminal Pro-Brain Natriuretic Peptide and troponin I could improve the diagnosis efficiency for the all-cause death or recurrence risk in acute pulmonary embolism patients.