Department of Cardiology, Concord General Repatriation Hospital, Sydney, Australia
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Purpose: Pulmonary embolus (PE) is associated with increased morbidity and mortality in long-term follow-up. However, it is unclear whether the initial transthoracic echocardiogram (TTE) can predict long-term outcome beyond six months, or whether there is a critical time window within which prognostically important information must be collected. The purpose of our study was to assess baseline echocardiographic & biochemical parameters that predict poor outcomes post PE.Methods: From 2004, 35 patients with newly diagnosed PE were prospectively recruited and intensively investigated with biochemical profiles (Troponin T, BNP, C-reactive protein) and serial echocardiography to assess right ventricular (RV) function on Days 1,2,5,42,84&182 following admission. All patients received therapeutic anticoagulation for a minimum of 6 months.Results: Mean follow-up was 4.3±1.9 years (yrs), with a mean age at diagnosis of 63.1±18.1yrs. There were 10 deaths (28.6%). 7 (20%) patients developed recurrent PE, with 4 patients receiving therapeutic anticoagulation at the time of recurrence. Significant univariate predictors of death include: age (74±10.7v59±18.2,p=0.004), systemic hypertension (p=0.006), underlying malignancy (p=0.007), ratio of right to left atrium (RA/LA) area (1.2±0.37 vs 0.89±0.26, p=0.01), systolic strain rate of apical right ventricular (RV) wall (p=0.04) and A' velocity of apical RV wall (p=0.04). Multivariate independent predictors of death are shown in Table 1. After incorporating RA/LA area ratio into multivariate model, RV dysfunction was not an independent predictor of long-term survival. A baseline RA/LA area ratio >0.89 has sensitivity of 78% and specificity of 64% in predicting death (AUC=0.76, p=0.02). Normalisation of the RA/LA area ratio occurred rapidly, typically within 5 days of presentation, and the RA/LA ratio measured even 2 days after presentation was not predictive of mortality.Conclusion: The RA/LA area ratio is a simple, novel and robust predictor of long-term mortality after acute PE, but only when measured on day 1 of presentation.