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Thromboembolic Diseases

Thromboembolic Diseases. 1. A 33 year old female patient admitted to the ICU with confirmed pulmonary embolism. It was noted that she had elevated serum troponin level. Does this indicate that she had a cardiac event? Is their any prognostic value for this?.

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Thromboembolic Diseases

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  1. Thromboembolic Diseases • 1. A 33 year old female patient admitted to the ICU with confirmed pulmonary embolism. It was noted that she had elevated serum troponin level. Does this indicate that she had a cardiac event? Is their any prognostic value for this?

  2. Prognostic Value of Troponins in AcutePulmonary EmbolismA Meta-Analysis Name Of study

  3. publishes a standard for providing basic and advanced life support, including standards for proper performance of cardiopulmonary resuscitation (CPR)

  4. 1. Write the study name • 2. Study type Interventional vs observational • 3. Outcome • 6. Time period • 7. Sample size • 8. Randomization • 9. Resutls and its detials.. age groups,,,etc • 10. Conclusions from the results

  5. Name of study • Prognostic Value of Troponins in AcutePulmonary Embolism (Meta Analysis)

  6. Is It A Trial? • Observational vs Interventional

  7. Study type

  8. Objective • primary objective: to assess whether High serum troponins are associated with Death in patients with acute pulmonary embolism (short term mortality)

  9. Objective • Secondary objectives: to assess whether High serum troponins are associated with Death (resulting from Pulmonary Embolism) or adverse outcome events (i.e shock, need for thrombolysis, endotracheal intubation, catecholamine infusion, cardiopulmonary resuscitation, or recurrent pulmonary embolism).

  10. Outcome • Primary outcome : Whether elevated serum troponin levels identify patients with acute pulmonary embolism at high risk of short-term mortality or adverse outcome is undefined.

  11. Methods The methods for this meta-analysis are in accordance with “Meta-Analysis of Observational Studies in Epidemiology: A Proposal for Reporting.

  12. Study Slection Search periods from Jan 1998 till Nov. 2006 ((key word)) [Pulmonary embolism and Troponin] used in MEDLINE and EMBASE Not Limited to english language Only full Article were considered for analysis??

  13. Study Slection (character of selected study) 1-Has objectivediagnosis of PE 2-Troponin sampling in initial in hospital phase 3-short-term death ( as an outcome )

  14. Study Slection 20 studies (1985 patients) were included in this study

  15. Sample size • (1985 patients)

  16. Data Extracted From The Study • Study design • Patients (number of included patients, mean age, gender) • Methods for diagnosis of pulmonary embolism • Hemodynamic status in the study • Treatment used for pulmonary embolism • troponin assays (name of the assay, type of examined troponin [I or T], cutoff level, timing of determination, and overall troponin-positive patients) • Primary end points (number of patients with the primary end point among troponin-positive or -negative patients • Secondary end points among troponin-positive and -negative patients).

  17. What are the type of selected study?Is it Case Control ?Crossectional ?Cohort?

  18. Characteristic of Selected Studies

  19. C C C C C C C C C C C

  20. For 5 of these studies, the numbers of patients who had died or had experienced an adverse outcome event were obtained by contacting the authors Study authors were contacted when their studies did not Report data, allowing the creation of a 2X2 table based on troponin levels (normal and elevated) and outcome (death and survival, adverse outcome events, and no adverse outcome events).

  21. Characteristic of Selected Studies

  22. Results • Overall 122 of 618 patients with high troponin levels died (19.7%; 95% confidence interval [CI], 16.6 to 22.8) compared with 51 of 1367 with normal troponin levels (3.7%; 95% CI, 2.7 to 4.7). • Is it significant difference? 16.6% 22.8% 2.7% 4.7%

  23. Results of primary end point • In 8 prospective studies (645 patients) reported on deaths resulting from pulmonary embolism. Overall, 40 events were observed: • 34 in 207 patients with High troponin (16.4%; 95% CI, 11.4 to 21.4) • 6 in 438 with normal troponin levels (1.4%; 95% CI, 0.8 to 1.9) 21.4 11.4 0.8 1.9

  24. Results of primary end point • Conclusion: Elevated troponin levels were associated with a high risk of (early) death resulting from pulmonary embolism (OR, 9.44; 95% CI, 4.14 to 21.49)

  25. Are There Possible bias in the result? • How they collect the death incidence data? Some study account: • In hospital death only? (not follow up the patient) Other study account • In hospital death and include Out side the hospital death? (up to 100 days)

  26. Time periods for primary end point • They considered death and adverse outcome events occurring in the short-term follow-up (in hospital or 30 days)??

  27. Other Possible Bias • Are Assay used to measure troponin are similar? • 3 different assays for troponin T were used With different cutoff points for abnormal levels. • 5 different assays for troponin I were used With different cutoff points for abnormal levels.

  28. Both significant because they not cross 1

  29. Among studies using the same troponin assay, ORs for mortality were higher in studies using higher troponin cutoffs

  30. Results • both I and T, were associated with a high risk of short-term death • result was consistent for either troponin I (OR, 4.01; 95% CI, 2.23to 7.23) or troponin T (OR, 7.95; 95% CI, 3.79 to 16.65). • Is there significant difference between TI &TT? 3.79 16.65 2.23 7.23

  31. Summary What does itmean to you?

  32. Result of Secondary End Point

  33. Results of secondary End point • Nine studies (530 patients), all with a prospective design. • The incidence of adverse outcome was 43.6% (92 of 211 patients; 95% CI, 36.9 to 50.3) in patients with elevated troponin levels and 14.7% (47 of 319 patients; 95% CI, 10.8 to 18.6) in patients without elevated troponin levels, respectively 36.9 50.3 10.8 18.6

  34. Result of Secondary End Point • Conclusion: elevated troponin levels were associated with a high risk of adverse events during the in-hospital phase (OR, 7.03; 95% CI, 2.42 to 20.43)

  35. Over all Results • Elevated troponin levels were significantly associated with death (short term) (odds ratio [OR], 5.24; 95% CI, 3.28 to 8.38), with death resulting from pulmonary embolism (OR, 9.44; 95% CI, 4.14 to 21.49), and with adverse outcome events (OR, 7.03; 95% CI, 2.42 to 20.43)

  36. Discussion & Conclusion • Elevated serum troponins identify a subgroup of patients with acute pulmonary embolism at high risk of in-hospital death and adverse outcome events. • The results of this meta-analysis suggest a role for troponin in the selection of hemodynamicallystable patients with a worse outcome who could potentially benefit from a more aggressive treatment.

  37. Conclussion • These findings identify troponin as a promising tool for rapid risk stratification of patients with pulmonary embolism. Prospective randomized studies are needed to evaluate the clinical benefits of more aggressive treatments in patients with pulmonary embolisms and elevated troponin levels.

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