Letter to the Editor
Contrast-enhanced multidetector computed tomography: A new prognosticator in acute pulmonary embolism?
Angiografia pulmonar por tomografia computadorizada: uma nova ferramenta prognóstica na tromboembolia pulmonar aguda?
Sérgio Barra
, Rui Providência, Luís Paiva
Corresponding author
Cardiology Department, Coimbra Hospital and University Centre - Hospital Geral, Centro Hospitalar de Coimbra, Coimbra, Portugal
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Axial (A) and multiplanar (B, C and D) reconstructions showing atrioventricular and ventriculoarterial discordance, with anterior right aorta and posterior left pulmonary artery, infundibular septal defect with subarterial communication (asterisk), and anomalous origin of the right coronary artery in the left coronary sinus, coursing between the aorta and the pulmonary artery. AD: right atrium; AE: left atrium; Ao: aorta; CD: right coronary artery; Cx: circumflex artery; DA: anterior descending artery; P: pulmonary artery; VD: right ventricle; VE: left ventricle.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ricardo Duarte, Maria Ana Sampaio, Humberto Morais, Constança Palma, João Carlos Costa, António Felipe Júnior" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Duarte" ] 1 => array:2 [ "nombre" => "Maria Ana" "apellidos" => "Sampaio" ] 2 => array:2 [ "nombre" => "Humberto" "apellidos" => "Morais" ] 3 => array:2 [ "nombre" => "Constança" "apellidos" => "Palma" ] 4 => array:2 [ "nombre" => "João Carlos" "apellidos" => "Costa" ] 5 => array:2 [ "nombre" => "António Felipe" "apellidos" => "Júnior" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001888?idApp=UINPBA00004E" "url" => "/21742049/0000003200000010/v1_201312121254/S2174204913001888/v1_201312121254/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Contrast-enhanced multidetector computed tomography: A new prognosticator in acute pulmonary embolism?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "839" "paginaFinal" => "840" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sérgio Barra, Rui Providência, Luís Paiva" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Sérgio" "apellidos" => "Barra" "email" => array:1 [ 0 => "sergioncbarra@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Rui" "apellidos" => "Providência" ] 2 => array:2 [ "nombre" => "Luís" "apellidos" => "Paiva" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, Coimbra Hospital and University Centre - Hospital Geral, Centro Hospitalar de Coimbra, Coimbra, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Angiografia pulmonar por tomografia computadorizada: uma nova ferramenta prognóstica na tromboembolia pulmonar aguda?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with interest the paper by Baptista et al., in which the authors propose that contrast-enhanced multidetector computed tomography (MDCT) may help assess prognosis in patients with intermediate- to high-risk pulmonary embolism (PE).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">MDCT has traditionally been used for diagnostic purposes, but its potential role as a prognosticator in PE has been the subject of several studies in the last few years. Araoz et al. suggested that ventricular septal bowing was predictive of death due to PE, albeit with low sensitivity and high interobserver variability, while right ventricular (RV)/left ventricular (LV) diameter ratio and embolic burden were not associated with short-term death.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Moreover, Van der Meer et al. assessed the predictive value of RV dysfunction and the pulmonary artery obstruction index (PAOI)<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> for 3-month mortality following the initial diagnosis of PE, and concluded that both the RV/LV ratio and the obstruction index were significant risk factors for mortality, while no such relationship was found for the ratio of pulmonary artery to ascending aorta diameters or for the shape of the interventricular septum.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> On the other hand, Ghuysen et al. found no association between the PAOI and patient outcome, although right to left ventricular minor axis ratio, proximal superior vena cava diameter, azygos vein diameter and presence of contrast regurgitation into the inferior vena cava were shown to predict in-hospital mortality.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> A score was constructed by Ghanima et al. using the mean value of the largest affected vessel (sub-segmental =1, segmental =2, lobar =3, main pulmonary artery =4) in each lung. The score was shown to relate to the severity of PE as determined by blood oxygenation, biochemical and radiological parameters, and the authors proposed it could be of value for rapid risk stratification of PE.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Furthermore, Rodrigues et al. tested the PAOI in their intermediate- to high-risk PE cohort and concluded that a score above 18 was an independent predictor of RV dysfunction and correlated linearly with variables associated with higher morbidity. In-hospital mortality was, nonetheless, similar in both patients with a PAOI >18 and those without.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The relationship between the extension and magnitude of the clot and the clinical severity of PE has also been studied by Ghanima et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and Wu et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However, to date, no consensus has been reached regarding which radiological parameters can predict mortality with the highest discriminative performance.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the small cohort and number of events on follow-up, Baptista and colleagues have made an attempt to clarify the role of MDCT as a potential prognosticator in PE, and their study is among the very few focusing on higher-risk patients. However, while their paper may influence other authors in pursuing the validation and quantification of this potential association in larger cohorts, some questions that were left unanswered may merit consideration.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0020" class="elsevierStylePara elsevierViewall">We might hypothesize that other MDCT parameters (such as obstruction ≥40% or LV diameter) could have been associated with short- to mid-term prognosis in a larger cohort. Also, although the reported association between RV/LV ratio and mid-term prognosis corroborates the findings of other investigators, a mere chance association cannot be excluded from a statistical point of view, given the low number of events. Nevertheless, the authors have attempted to mitigate this issue by demonstrating a correlation between RV/LV ratio and some parameters of usual prognostic significance, such as age, heart rate and troponin I, which adds some robustness to their thesis. Furthermore, it should be borne in mind that studies involving large cohorts of high-risk PE patients are indeed scarce.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0025" class="elsevierStylePara elsevierViewall">Their study does not tell us whether MDCT can add prognostic value to currently available risk scores or even to isolated clinical variables known to predict mortality. To our knowledge, this topic has not been properly addressed by the scientific community. The potential prognostic role of MDCT may not reach clinical significance if it does not add prognostic power to currently available risk stratification tools. Multivariate analysis in the aforementioned investigation to evaluate whether RV/LV ratio would be an independent predictor of mortality could have provided new insights into this matter.</p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">Currently, risk scores such as PESI,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> simplified PESI,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> 48-hour PESI,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Geneva,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> LR-PED<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and GRACE,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> mostly incorporating clinical and laboratory variables, provide the most reliable risk stratification in PE, especially PESI, as the last two await proper validation in independent samples. Hopefully, future research will clarify whether the addition of radiological parameters will improve PE risk stratification. Also, as there is growing evidence that early discharge or outpatient management is safe and feasible in many patients with non-massive PE,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and as Aujesky et al. found low molecular weight heparin treatment of PE to be cost-saving if ≥8% of patients were eligible for early discharge (or if ≥5% of patients could be treated as outpatients),<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> identification of the lowest-risk PE subgroups should be an additional goal for every physician caring for patients with acute pulmonary thromboembolism. Using clinical, laboratory and radiological ineligibility criteria for outpatient treatment may be the most accurate way of identifying truly low-risk patients eligible for outpatient anticoagulant treatment. Hopefully, this might be addressed in future studies.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "One-shot diagnostic and prognostic assessment in intermediate- to high-risk acute pulmonary embolism: the role of multidetector computed tomography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 4 | 8 |
| 2024 October | 29 | 30 | 59 |
| 2024 September | 42 | 18 | 60 |
| 2024 August | 33 | 26 | 59 |
| 2024 July | 34 | 29 | 63 |
| 2024 June | 23 | 22 | 45 |
| 2024 May | 54 | 23 | 77 |
| 2024 April | 25 | 19 | 44 |
| 2024 March | 23 | 14 | 37 |
| 2024 February | 25 | 22 | 47 |
| 2024 January | 24 | 23 | 47 |
| 2023 December | 30 | 25 | 55 |
| 2023 November | 24 | 21 | 45 |
| 2023 October | 11 | 21 | 32 |
| 2023 September | 15 | 25 | 40 |
| 2023 August | 24 | 19 | 43 |
| 2023 July | 16 | 22 | 38 |
| 2023 June | 15 | 16 | 31 |
| 2023 May | 26 | 26 | 52 |
| 2023 April | 15 | 5 | 20 |
| 2023 March | 16 | 23 | 39 |
| 2023 February | 21 | 19 | 40 |
| 2023 January | 16 | 12 | 28 |
| 2022 December | 36 | 23 | 59 |
| 2022 November | 43 | 25 | 68 |
| 2022 October | 28 | 18 | 46 |
| 2022 September | 18 | 50 | 68 |
| 2022 August | 25 | 30 | 55 |
| 2022 July | 30 | 33 | 63 |
| 2022 June | 15 | 21 | 36 |
| 2022 May | 23 | 32 | 55 |
| 2022 April | 24 | 31 | 55 |
| 2022 March | 21 | 27 | 48 |
| 2022 February | 18 | 22 | 40 |
| 2022 January | 16 | 28 | 44 |
| 2021 December | 13 | 27 | 40 |
| 2021 November | 38 | 36 | 74 |
| 2021 October | 38 | 38 | 76 |
| 2021 September | 43 | 28 | 71 |
| 2021 August | 26 | 45 | 71 |
| 2021 July | 16 | 31 | 47 |
| 2021 June | 16 | 20 | 36 |
| 2021 May | 22 | 34 | 56 |
| 2021 April | 37 | 25 | 62 |
| 2021 March | 43 | 14 | 57 |
| 2021 February | 37 | 14 | 51 |
| 2021 January | 20 | 9 | 29 |
| 2020 December | 29 | 8 | 37 |
| 2020 November | 21 | 13 | 34 |
| 2020 October | 4 | 8 | 12 |
| 2020 September | 20 | 8 | 28 |
| 2020 August | 16 | 7 | 23 |
| 2020 July | 19 | 8 | 27 |
| 2020 June | 23 | 6 | 29 |
| 2020 May | 34 | 2 | 36 |
| 2020 April | 36 | 5 | 41 |
| 2020 March | 29 | 5 | 34 |
| 2020 February | 18 | 9 | 27 |
| 2020 January | 14 | 9 | 23 |
| 2019 December | 23 | 3 | 26 |
| 2019 November | 17 | 2 | 19 |
| 2019 October | 16 | 8 | 24 |
| 2019 September | 16 | 11 | 27 |
| 2019 August | 24 | 4 | 28 |
| 2019 July | 20 | 14 | 34 |
| 2019 June | 22 | 5 | 27 |
| 2019 May | 20 | 8 | 28 |
| 2019 April | 19 | 16 | 35 |
| 2019 March | 26 | 10 | 36 |
| 2019 February | 17 | 13 | 30 |
| 2019 January | 21 | 16 | 37 |
| 2018 December | 26 | 6 | 32 |
| 2018 November | 44 | 12 | 56 |
| 2018 October | 77 | 21 | 98 |
| 2018 September | 17 | 8 | 25 |
| 2018 August | 31 | 5 | 36 |
| 2018 July | 20 | 3 | 23 |
| 2018 June | 18 | 3 | 21 |
| 2018 May | 23 | 10 | 33 |
| 2018 April | 26 | 2 | 28 |
| 2018 March | 21 | 7 | 28 |
| 2018 February | 17 | 5 | 22 |
| 2018 January | 15 | 13 | 28 |
| 2017 December | 24 | 12 | 36 |
| 2017 November | 13 | 9 | 22 |
| 2017 October | 13 | 10 | 23 |
| 2017 September | 19 | 10 | 29 |
| 2017 August | 26 | 13 | 39 |
| 2017 July | 14 | 6 | 20 |
| 2017 June | 25 | 8 | 33 |
| 2017 May | 34 | 7 | 41 |
| 2017 April | 33 | 1 | 34 |
| 2017 March | 42 | 36 | 78 |
| 2017 February | 27 | 4 | 31 |
| 2017 January | 23 | 4 | 27 |
| 2016 December | 22 | 10 | 32 |
| 2016 November | 15 | 2 | 17 |
| 2016 October | 25 | 9 | 34 |
| 2016 September | 10 | 4 | 14 |
| 2016 August | 5 | 1 | 6 |
| 2016 July | 6 | 2 | 8 |
| 2016 June | 7 | 3 | 10 |
| 2016 May | 8 | 2 | 10 |
| 2016 April | 16 | 5 | 21 |
| 2016 March | 36 | 7 | 43 |
| 2016 February | 36 | 8 | 44 |
| 2016 January | 25 | 5 | 30 |
| 2015 December | 18 | 3 | 21 |
| 2015 November | 22 | 3 | 25 |
| 2015 October | 32 | 8 | 40 |
| 2015 September | 19 | 5 | 24 |
| 2015 August | 34 | 9 | 43 |
| 2015 July | 23 | 3 | 26 |
| 2015 June | 14 | 1 | 15 |
| 2015 May | 27 | 8 | 35 |
| 2015 April | 14 | 10 | 24 |
| 2015 March | 14 | 3 | 17 |
| 2015 February | 16 | 1 | 17 |
| 2015 January | 20 | 3 | 23 |
| 2014 December | 17 | 6 | 23 |
| 2014 November | 12 | 1 | 13 |
| 2014 October | 16 | 4 | 20 |
| 2014 September | 26 | 3 | 29 |
| 2014 August | 8 | 4 | 12 |
| 2014 July | 18 | 5 | 23 |
| 2014 June | 10 | 4 | 14 |
| 2014 May | 15 | 2 | 17 |
| 2014 April | 12 | 2 | 14 |
| 2014 March | 21 | 11 | 32 |
| 2014 February | 22 | 8 | 30 |
| 2014 January | 40 | 14 | 54 |
| 2013 December | 13 | 6 | 19 |
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