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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We are grateful to Drs Barra&#44; Provid&#234;ncia and Paiva for their comments on our paper&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> They suggest that we cannot exclude that the association between RV&#47;LV ratio and mortality is due to chance and hypothesize that other parameters could be predictive of prognosis in a larger cohort&#46; We should emphasize that in contrast to most reports on the prognostic value of MCDT&#44; which usually include unselected populations of low- to intermediate-risk PE &#40;mean RV&#47;LV ratio &#60;1&#46;5&#41;&#44; we have studied a very specific population&#44; reflected by the elevated mean RV&#47;LV ratio &#40;&#62;1&#46;6&#41;&#46; This fact had an impact on the cohort size&#44; leading to a low statistical power&#46; However&#44; even in such a small cohort&#44; and in contrast to every other MCDT-derived index&#44; such as obstruction burden &#40;as either a continuous or a dichotomous variable&#41;&#44; the RV&#47;LV ratio emerged as the only one that was significantly different between the two groups&#46; We believe that our results reflect a real difference&#44; although from a statistical point of view we cannot exclude a chance association&#58; however&#44; we can estimate that probability to be under 5&#37;&#46; Our results are also in line with other observations&#44; such as those in a recent paper by Becattini et al&#46; with more than 450 patients demonstrating that a RV&#47;LV ratio &#60;0&#46;9 has a 100&#37; negative predictive value for death due to PE and is an independent predictor of mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Lastly&#44; the RV&#47;LV ratio correlated with other surrogate markers of worse prognosis&#46; Unfortunately&#44; we cannot speculate whether other variables could have been predictive of prognosis in a larger cohort with similar clinical profile&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Additionally&#44; Dr Barra et al&#46; state that our study does not say whether MDCT can add prognostic value to currently available clinical risk scores &#40;CRS&#41;&#46; It should be recalled that the aim of our work was to compare radiological parameters in terms of their ability to predict long-term mortality and not to analyze their additional value to current clinical stratification systems&#46; Although evidence is growing regarding the role of CRS in the identification of lower-risk patients who can be safely discharged home&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> their prognostic value for intermediate- and high-risk PE is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; none of the available prospectively validated CRS include information from a key prognostic determinant&#44; right ventricular function&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and neither PESI nor sPESI were specifically studied regarding the decision whether to proceed to thrombolysis&#46; A recent scientific statement from the American Heart Association on the management of massive and submassive PE continues to support the use of clinical signs of impending shock&#47;respiratory distress and evidence of RV impairment&#47;injury for the selection of patients suitable for thrombolysis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The usefulness of a CRS versus an isolated risk marker will always be dependent on a balance between incremental prognostic value versus simplicity and consequent clinical application in everyday clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; the performance of a CRS may be different depending on whether the aim is to identify low-risk PE patients that can be safely discharged home or to select high-risk patients for thrombolysis&#46; Although evidence is already available for the former&#44; the question whether the combination of a CRS with imaging or laboratory parameters is better than each one alone for selecting patients for thrombolysis remains to be answered&#46; In the recently presented multicenter PEITHO trial&#44; patients with the simultaneous presence of RV dysfunction &#40;in around half of patients using MDCT&#41; and a positive troponin test were randomized to tenecteplase or placebo &#40;personal communication&#44; S Konstantinides&#44; American College of Cardiology&#44; 2013&#41;&#46; Seven-day all-cause mortality in this intermediate-risk population was less than 2&#37; in both arms&#44; lower than that reported in the MAPPET-3 trial&#44; in which patients were selected based only on RV dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Dr Barra et al&#46; also suggest the use of multivariate analysis to assess the independent value of RV&#47;LV ratio for prognostication&#46; Although we do not question the usefulness of such methodology&#44; we deliberately chose not to perform it&#44; since the minimum number of events per variable needed is at least five to nine&#44; and preferably greater than 10&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Therefore&#44; the five events recorded might yield an insurmountable bias&#46; However&#44; we consider that the novel demonstration that the RV&#47;LV ratio is also associated with mortality in a specific group of PE patients with a severely compromised RV is of clinical interest&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Letter to the Editor
Reply to the Letter to the Editor “Contrast-enhanced multidetector computed tomography: A new prognosticator in acute pulmonary embolism?”
Resposta à Carta ao Editor «Angiografia pulmonar por tomografia computadorizada: uma nova ferramenta prognóstica na tromboembolia pulmonar aguda?»
Rui Baptistaa,c,
Corresponding author
ruibaptista@gmail.com

Corresponding author.
, Rogério Teixeirab,c, Elisabete Jorgea,c, Pedro Monteiroa,c
a Serviço de Cardiologia, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
b Serviço de Cardiologia, Hospital Beatriz Ângelo, Loures, Portugal
c Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We are grateful to Drs Barra&#44; Provid&#234;ncia and Paiva for their comments on our paper&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> They suggest that we cannot exclude that the association between RV&#47;LV ratio and mortality is due to chance and hypothesize that other parameters could be predictive of prognosis in a larger cohort&#46; We should emphasize that in contrast to most reports on the prognostic value of MCDT&#44; which usually include unselected populations of low- to intermediate-risk PE &#40;mean RV&#47;LV ratio &#60;1&#46;5&#41;&#44; we have studied a very specific population&#44; reflected by the elevated mean RV&#47;LV ratio &#40;&#62;1&#46;6&#41;&#46; This fact had an impact on the cohort size&#44; leading to a low statistical power&#46; However&#44; even in such a small cohort&#44; and in contrast to every other MCDT-derived index&#44; such as obstruction burden &#40;as either a continuous or a dichotomous variable&#41;&#44; the RV&#47;LV ratio emerged as the only one that was significantly different between the two groups&#46; We believe that our results reflect a real difference&#44; although from a statistical point of view we cannot exclude a chance association&#58; however&#44; we can estimate that probability to be under 5&#37;&#46; Our results are also in line with other observations&#44; such as those in a recent paper by Becattini et al&#46; with more than 450 patients demonstrating that a RV&#47;LV ratio &#60;0&#46;9 has a 100&#37; negative predictive value for death due to PE and is an independent predictor of mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Lastly&#44; the RV&#47;LV ratio correlated with other surrogate markers of worse prognosis&#46; Unfortunately&#44; we cannot speculate whether other variables could have been predictive of prognosis in a larger cohort with similar clinical profile&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Additionally&#44; Dr Barra et al&#46; state that our study does not say whether MDCT can add prognostic value to currently available clinical risk scores &#40;CRS&#41;&#46; It should be recalled that the aim of our work was to compare radiological parameters in terms of their ability to predict long-term mortality and not to analyze their additional value to current clinical stratification systems&#46; Although evidence is growing regarding the role of CRS in the identification of lower-risk patients who can be safely discharged home&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> their prognostic value for intermediate- and high-risk PE is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; none of the available prospectively validated CRS include information from a key prognostic determinant&#44; right ventricular function&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and neither PESI nor sPESI were specifically studied regarding the decision whether to proceed to thrombolysis&#46; A recent scientific statement from the American Heart Association on the management of massive and submassive PE continues to support the use of clinical signs of impending shock&#47;respiratory distress and evidence of RV impairment&#47;injury for the selection of patients suitable for thrombolysis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The usefulness of a CRS versus an isolated risk marker will always be dependent on a balance between incremental prognostic value versus simplicity and consequent clinical application in everyday clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; the performance of a CRS may be different depending on whether the aim is to identify low-risk PE patients that can be safely discharged home or to select high-risk patients for thrombolysis&#46; Although evidence is already available for the former&#44; the question whether the combination of a CRS with imaging or laboratory parameters is better than each one alone for selecting patients for thrombolysis remains to be answered&#46; In the recently presented multicenter PEITHO trial&#44; patients with the simultaneous presence of RV dysfunction &#40;in around half of patients using MDCT&#41; and a positive troponin test were randomized to tenecteplase or placebo &#40;personal communication&#44; S Konstantinides&#44; American College of Cardiology&#44; 2013&#41;&#46; Seven-day all-cause mortality in this intermediate-risk population was less than 2&#37; in both arms&#44; lower than that reported in the MAPPET-3 trial&#44; in which patients were selected based only on RV dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Dr Barra et al&#46; also suggest the use of multivariate analysis to assess the independent value of RV&#47;LV ratio for prognostication&#46; Although we do not question the usefulness of such methodology&#44; we deliberately chose not to perform it&#44; since the minimum number of events per variable needed is at least five to nine&#44; and preferably greater than 10&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Therefore&#44; the five events recorded might yield an insurmountable bias&#46; However&#44; we consider that the novel demonstration that the RV&#47;LV ratio is also associated with mortality in a specific group of PE patients with a severely compromised RV is of clinical interest&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Article information
ISSN: 21742049
Original language: English
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Idiomas
Revista Portuguesa de Cardiologia (English edition)
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