Acute pulmonary embolism: MDCT & biomarkers

1. Acute pulmonary embolism: MDCT & biomarkers Cecilia Becattini University of Perugia

2. Acute pulmonary embolism: MDCT & biomarkers • MDCT to diagnose PE • MDCT for prognostic stratification • serum biomarkers

3. Acute pulmonary embolism: MDCT & biomarkers • MDCT to diagnose PE • MDCT for prognostic stratification • serum biomarkers

4. 16 x 0.75 mm 10 sec 64 x 0.625 mm 4 sec 4-slice CT 1998 4 x 1 mm 25 sec 16-slice CT 2002 64-slice 2004 PE at MDCT 2-slice CT 1992 2 x 2.7 mm 25 sec

5. Pulmonary arteries at MDCT 96% of subsegmental arteries and 54% of sub-subsegmental arteries are identified on multislice CT (4 rows of detectors)

6. PE at MDCT

7. 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

8. Diagnosis of PE in un-stable patients Echocardiography RVD present No RVD Treat & stabilize Search for alternative diagnosis Multidetector CT

9. The heart at MDCT sagittal coronal 4-chamber

10. CT: prognostic markers • RV/LV short axis diameter ratio (>1) • Obstruction index • Pulmonary artery to ascending aorta diameter • Shape of interventricular septum

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

12. 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

13. RVD at CT: prognostic value 431 patients with acute PE Schoepf, Circulation 2004

14. RV LV Multidetector CT and Short-term Outcome PE MAP study

15. 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

16. 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

17. 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

18. 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

19. RV LV

20. 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)

22. RV LV Multidetector CT and Short-term Outcome PE MAP study See you in Florence!!

23. Acute pulmonary embolism: MDCT & biomarkers • MDCT to diagnose PE • MDCT for prognostic stratification • serum biomarkers

24. 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

25. 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 < 0.05) Becattini et al. Circulation, 2007

26. BNP and Short-term Outcome

27. 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

28. Acute pulmonary embolism: MDCT & biomarkers Cecilia Becattini University of Perugia