Pulmonary embolism laboratory findings: Difference between revisions
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==Overview== | ==Overview== | ||
Routine laboratory tests including [[ABG|arterial blood gas]] analysis are non-specific in patients with acute pulmonary embolism; however, in cases of suspected PE they may be ordered to rule-out secondary causes. | |||
== | ==Laboratory tests== | ||
*In patients with '''''acute''''' pulmonary embolism, routine laboratory findings are '''''non-specific''''' and include: [[leukocytosis]], [[erythrocyte sedimentation rate|elevated ESR]] with an elevated [[LDH|serum LDH]] and [[transaminases|serum transaminase]] (especially [[Aspartate transaminase|AST or SGOT]]). However, [[bilirubin|serum bilirubin]] levels are found to be within normal limits. | |||
*In patients with '''''suspected''''' pulmonary embolism, routine laboratory tests are ordered to '''''exclude the secondary causes''''' of PE. These tests include: | |||
* | :*[[Complete blood count]], | ||
:*[[Erythrocyte sedimentation rate]], | |||
:*[[Coagulation studies]], | |||
:*Other screening tests such as [[renal function tests]], [[LFT|liver function tests]] and [[electrolyte|electrolyte]] assessment. | |||
==Arterial blood gas (ABG)== | |||
*A study had shown, that in patients without prior cardiopulmonary disease, 98% of patients with PE had either an increased Alveolar-arterial oxygen difference (AaDO2) or [[hypocapnia]].<ref name="pmid2491801">{{cite journal| author=Cvitanic O, Marino PL| title=Improved use of arterial blood gas analysis in suspected pulmonary embolism. | journal=Chest | year= 1989 | volume= 95 | issue= 1 | pages= 48-51 | pmid=2491801 | doi= |pmc= | url= }} </ref> | |||
*In a patient without cardiopulmonary disease, having a normal AaDO2 and a normal PaCO2, the probability of PE is very unlikely (i.e. 2%). | |||
* Other studies have found ABG lacking enough sensitivity, specificity, positive or negative predictive value to either diagnose PE or prevent further testing in patients thought to have PE.<ref name="pmid17145249">{{cite journal| author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD et al.| title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. | journal=Am J Med | year= 2006 | volume= 119 | issue= 12 | pages= 1048-55 | pmid=17145249 | doi=10.1016/j.amjmed.2006.05.060 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17145249 }}</ref> | * Other studies have found ABG lacking enough sensitivity, specificity, positive or negative predictive value to either diagnose PE or prevent further testing in patients thought to have PE.<ref name="pmid17145249">{{cite journal| author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD et al.| title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. | journal=Am J Med | year= 2006 | volume= 119 | issue= 12 | pages= 1048-55 | pmid=17145249 | doi=10.1016/j.amjmed.2006.05.060 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17145249 }}</ref> | ||
== | ==D-dimers== | ||
This is formed by the degradation of fibrin clot. Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer. | This is formed by the degradation of fibrin clot. Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer. | ||
* The negative predictive value (when done by ELISA) is 91% – 94% . | * The negative predictive value (when done by ELISA) is 91% – 94% . | ||
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A new D-Dimer (DDMR) analyzer has shown to have higher accuracy in excluding patients with non-high clinical pre-test probability.<ref name="pmid22245223">{{cite journal| author=Gosselin RC, Wu JR, Kottke-Marchant K, Peetz D, Christie DJ, Muth H et al.| title=Evaluation of the Stratus® CS Acute Care™ D-dimer assay (DDMR) using the Stratus® CS STAT Fluorometric Analyzer: A prospective multisite study for exclusion of pulmonary embolism and deep vein thrombosis. | journal=Thromb Res | year= 2012 | volume= | issue= | pages= | pmid=22245223 | doi=10.1016/j.thromres.2011.12.015 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22245223 }} </ref> | A new D-Dimer (DDMR) analyzer has shown to have higher accuracy in excluding patients with non-high clinical pre-test probability.<ref name="pmid22245223">{{cite journal| author=Gosselin RC, Wu JR, Kottke-Marchant K, Peetz D, Christie DJ, Muth H et al.| title=Evaluation of the Stratus® CS Acute Care™ D-dimer assay (DDMR) using the Stratus® CS STAT Fluorometric Analyzer: A prospective multisite study for exclusion of pulmonary embolism and deep vein thrombosis. | journal=Thromb Res | year= 2012 | volume= | issue= | pages= | pmid=22245223 | doi=10.1016/j.thromres.2011.12.015 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22245223 }} </ref> | ||
== | ==Brain natriuretic peptide (BNP)== | ||
In a case-control study of 2213 hemodynamically stable patients with suspected acute PE, BNP was found to have 60% sensitivity and 62% specificity.<ref name="pmid16405522">{{cite journal| author=Söhne M, Ten Wolde M, Boomsma F, Reitsma JB, Douketis JD, Büller HR| title=Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. | journal=J Thromb Haemost | year= 2006 | volume= 4 | issue= 3 | pages= 552-6 | pmid=16405522 | doi=10.1111/j.1538-7836.2005.01752.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16405522 }} </ref> | In a case-control study of 2213 hemodynamically stable patients with suspected acute PE, BNP was found to have 60% sensitivity and 62% specificity.<ref name="pmid16405522">{{cite journal| author=Söhne M, Ten Wolde M, Boomsma F, Reitsma JB, Douketis JD, Büller HR| title=Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. | journal=J Thromb Haemost | year= 2006 | volume= 4 | issue= 3 | pages= 552-6 | pmid=16405522 | doi=10.1111/j.1538-7836.2005.01752.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16405522 }} </ref> | ||
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In hemodynamically stable patients, normal level of BNP and pro-BNP have 100% negative predictive value (NPV) for an adverse outcome.<ref name="pmid20592294">{{cite journal| author=Agnelli G, Becattini C| title=Acute pulmonary embolism. | journal=N Engl J Med | year= 2010 | volume= 363 | issue= 3 | pages= 266-74 | pmid=20592294 | doi=10.1056/NEJMra0907731 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20592294 }} </ref> High level of BNP distinguish patients with pulmonary embolism at higher risk of complicated in-hospital duration and death, when compared with those with low BNP levels. However an isolated increase in BNP or NT-pro-BNP level, do not justify more invasive treatment regimens.<ref name="pmid18556626">{{cite journal| author=Klok FA, Mos IC, Huisman MV| title=Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. | journal=Am J Respir Crit Care Med | year= 2008 | volume= 178 | issue= 4 | pages= 425-30 | pmid=18556626 | doi=10.1164/rccm.200803-459OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18556626 }} </ref> | In hemodynamically stable patients, normal level of BNP and pro-BNP have 100% negative predictive value (NPV) for an adverse outcome.<ref name="pmid20592294">{{cite journal| author=Agnelli G, Becattini C| title=Acute pulmonary embolism. | journal=N Engl J Med | year= 2010 | volume= 363 | issue= 3 | pages= 266-74 | pmid=20592294 | doi=10.1056/NEJMra0907731 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20592294 }} </ref> High level of BNP distinguish patients with pulmonary embolism at higher risk of complicated in-hospital duration and death, when compared with those with low BNP levels. However an isolated increase in BNP or NT-pro-BNP level, do not justify more invasive treatment regimens.<ref name="pmid18556626">{{cite journal| author=Klok FA, Mos IC, Huisman MV| title=Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. | journal=Am J Respir Crit Care Med | year= 2008 | volume= 178 | issue= 4 | pages= 425-30 | pmid=18556626 | doi=10.1164/rccm.200803-459OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18556626 }} </ref> | ||
== | ==Troponin== | ||
Serum troponin I and troponin T are elevated in approximately thirty to fifty percent of the PE patients.<ref name="pmid12904706">{{cite journal| author=Horlander KT, Leeper KV| title=Troponin levels as a guide to treatment of pulmonary embolism. | journal=Curr Opin Pulm Med | year= 2003 | volume= 9 | issue= 5 | pages= 374-7 | pmid=12904706 | doi= | pmc= | url= }} </ref><ref name="pmid12208803">{{cite journal| author=Konstantinides S, Geibel A, Olschewski M, Kasper W, Hruska N, Jäckle S et al.| title=Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism. | journal=Circulation | year= 2002 | volume= 106 | issue= 10 | pages= 1263-8 | pmid=12208803 | doi= | pmc= | url= }} </ref> The suspected mechanism is due to acute right heart overload.<ref name="pmid11079669">{{cite journal| author=Meyer T, Binder L, Hruska N, Luthe H, Buchwald AB| title=Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. | journal=J Am Coll Cardiol | year= 2000 | volume= 36 | issue= 5 | pages= 1632-6 | pmid=11079669 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11079669 }} </ref> Troponin elevation is more prolonged in acute MI rather in PE and usually resolve within 40 hours after a PE event.<ref name="pmid11901075">{{cite journal| author=Müller-Bardorff M, Weidtmann B, Giannitsis E, Kurowski V, Katus HA| title=Release kinetics of cardiac troponin T in survivors of confirmed severe pulmonary embolism. | journal=Clin Chem | year= 2002 | volume= 48 | issue= 4 | pages= 673-5 | pmid=11901075 | doi= | pmc= | url= }} </ref> Thus troponins are not useful for diagnosis, but there role in prognostic assessment has been proved in a meta-analysis.<ref name="pmid18094010">{{cite journal| author=Jiménez D, Díaz G, Molina J, Martí D, Del Rey J, García-Rull S et al.| title=Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. | journal=Eur Respir J | year= 2008 | volume= 31 | issue= 4 | pages= 847-53 | pmid=18094010 | doi=10.1183/09031936.00113307 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18094010 }} </ref> | Serum troponin I and troponin T are elevated in approximately thirty to fifty percent of the PE patients.<ref name="pmid12904706">{{cite journal| author=Horlander KT, Leeper KV| title=Troponin levels as a guide to treatment of pulmonary embolism. | journal=Curr Opin Pulm Med | year= 2003 | volume= 9 | issue= 5 | pages= 374-7 | pmid=12904706 | doi= | pmc= | url= }} </ref><ref name="pmid12208803">{{cite journal| author=Konstantinides S, Geibel A, Olschewski M, Kasper W, Hruska N, Jäckle S et al.| title=Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism. | journal=Circulation | year= 2002 | volume= 106 | issue= 10 | pages= 1263-8 | pmid=12208803 | doi= | pmc= | url= }} </ref> The suspected mechanism is due to acute right heart overload.<ref name="pmid11079669">{{cite journal| author=Meyer T, Binder L, Hruska N, Luthe H, Buchwald AB| title=Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. | journal=J Am Coll Cardiol | year= 2000 | volume= 36 | issue= 5 | pages= 1632-6 | pmid=11079669 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11079669 }} </ref> Troponin elevation is more prolonged in acute MI rather in PE and usually resolve within 40 hours after a PE event.<ref name="pmid11901075">{{cite journal| author=Müller-Bardorff M, Weidtmann B, Giannitsis E, Kurowski V, Katus HA| title=Release kinetics of cardiac troponin T in survivors of confirmed severe pulmonary embolism. | journal=Clin Chem | year= 2002 | volume= 48 | issue= 4 | pages= 673-5 | pmid=11901075 | doi= | pmc= | url= }} </ref> Thus troponins are not useful for diagnosis, but there role in prognostic assessment has been proved in a meta-analysis.<ref name="pmid18094010">{{cite journal| author=Jiménez D, Díaz G, Molina J, Martí D, Del Rey J, García-Rull S et al.| title=Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. | journal=Eur Respir J | year= 2008 | volume= 31 | issue= 4 | pages= 847-53 | pmid=18094010 | doi=10.1183/09031936.00113307 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18094010 }} </ref> | ||
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[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Laboratory Tests]] | |||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Revision as of 17:33, 30 April 2012
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Pulmonary embolism laboratory findings On the Web |
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Routine laboratory tests including arterial blood gas analysis are non-specific in patients with acute pulmonary embolism; however, in cases of suspected PE they may be ordered to rule-out secondary causes.
Laboratory tests
- In patients with acute pulmonary embolism, routine laboratory findings are non-specific and include: leukocytosis, elevated ESR with an elevated serum LDH and serum transaminase (especially AST or SGOT). However, serum bilirubin levels are found to be within normal limits.
- In patients with suspected pulmonary embolism, routine laboratory tests are ordered to exclude the secondary causes of PE. These tests include:
- Complete blood count,
- Erythrocyte sedimentation rate,
- Coagulation studies,
- Other screening tests such as renal function tests, liver function tests and electrolyte assessment.
Arterial blood gas (ABG)
- A study had shown, that in patients without prior cardiopulmonary disease, 98% of patients with PE had either an increased Alveolar-arterial oxygen difference (AaDO2) or hypocapnia.[1]
- In a patient without cardiopulmonary disease, having a normal AaDO2 and a normal PaCO2, the probability of PE is very unlikely (i.e. 2%).
- Other studies have found ABG lacking enough sensitivity, specificity, positive or negative predictive value to either diagnose PE or prevent further testing in patients thought to have PE.[2]
D-dimers
This is formed by the degradation of fibrin clot. Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer.
- The negative predictive value (when done by ELISA) is 91% – 94% .
- Many other diseases are associated with a mild degree of fibrinolysis, and hence an elevated D-dimer is not specific for pulmonary embolism. Disease with elevated levels of D-dimer are:
D-Dimer levels are elevated in other medical conditions such as:
- Pregnancy
- After surgery
- Hospitalized patient.[3] Thus, most hospitalized patients should not undergo D-dimer testing if PE is suspected.[4]
Patients who are hemodynamically stable, but have a high clinical probability or those having a high d-dimer level should undergo multidetector CT.[5] The following table depicts the incidences of thromboembolic events in hemodynamicaly stable patients.
| Condition | Incidence of thromboembolic event (%) |
|---|---|
| Patients not receiving anticoagulation and with negative CT findings. | 1.5%[6][5] |
| Patients with High d-dimer level | 1.5% |
| Patients with Normal d-dimer level | 0.5%[6] |
In low-to-moderate suspicion of PE, a normal D-dimer level (shown in a blood test) is enough to exclude the possibility of thrombotic PE.[7] In patients with High clinical probability, the use of the d-dimer assay is of limited value.[8]
The following flowchart summarize the role of D-dimer:
| Patients with suspection of Pulmonary embolism | |||||||||||||||||||||||
| Clinically Low or Moderate | Clinically High | ||||||||||||||||||||||
| D-Dimer Positive | |||||||||||||||||||||||
| D-Dimer Negative | |||||||||||||||||||||||
| No treatment | Further Tests | Further Tests | |||||||||||||||||||||
A new D-Dimer (DDMR) analyzer has shown to have higher accuracy in excluding patients with non-high clinical pre-test probability.[9]
Brain natriuretic peptide (BNP)
In a case-control study of 2213 hemodynamically stable patients with suspected acute PE, BNP was found to have 60% sensitivity and 62% specificity.[10]
BNP levels are typically higher in PE patients as compared to patients without PE; however, certain features limit its usefulness as a diagnostic test:
- Many patients with PE do not have elevated BNP levels.
- There are many alternative causes of an elevated BNP level (proving it to be nonspecific).[11]
In hemodynamically stable patients, normal level of BNP and pro-BNP have 100% negative predictive value (NPV) for an adverse outcome.[4] High level of BNP distinguish patients with pulmonary embolism at higher risk of complicated in-hospital duration and death, when compared with those with low BNP levels. However an isolated increase in BNP or NT-pro-BNP level, do not justify more invasive treatment regimens.[12]
Troponin
Serum troponin I and troponin T are elevated in approximately thirty to fifty percent of the PE patients.[13][14] The suspected mechanism is due to acute right heart overload.[15] Troponin elevation is more prolonged in acute MI rather in PE and usually resolve within 40 hours after a PE event.[16] Thus troponins are not useful for diagnosis, but there role in prognostic assessment has been proved in a meta-analysis.[17]
References
- ↑ Cvitanic O, Marino PL (1989). "Improved use of arterial blood gas analysis in suspected pulmonary embolism". Chest. 95 (1): 48–51. PMID 2491801.
- ↑ Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD; et al. (2006). "Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators". Am J Med. 119 (12): 1048–55. doi:10.1016/j.amjmed.2006.05.060. PMID 17145249.
- ↑ Bruinstroop E, van de Ree MA, Huisman MV (2009). "The use of D-dimer in specific clinical conditions: a narrative review". Eur J Intern Med. 20 (5): 441–6. doi:10.1016/j.ejim.2008.12.004. PMID 19712840.
- ↑ 4.0 4.1 Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.
- ↑ 5.0 5.1 van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW; et al. (2006). "Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography". JAMA. 295 (2): 172–9. doi:10.1001/jama.295.2.172. PMID 16403929.
- ↑ 6.0 6.1 Perrier A, Roy PM, Sanchez O, Le Gal G, Meyer G, Gourdier AL; et al. (2005). "Multidetector-row computed tomography in suspected pulmonary embolism". N Engl J Med. 352 (17): 1760–8. doi:10.1056/NEJMoa042905. PMID 15858185. in: J Fam Pract. 2005 Aug;54(8):653, 657
- ↑ Bounameaux H, de Moerloose P, Perrier A, Reber G (1994). "Plasma measurement of D-dimer as diagnostic aid in suspected venous thromboembolism: an overview". Thromb. Haemost. 71 (1): 1–6. PMID 8165626.
- ↑ Gupta RT, Kakarla RK, Kirshenbaum KJ, Tapson VF (2009). "D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism". AJR Am J Roentgenol. 193 (2): 425–30. doi:10.2214/AJR.08.2186. PMID 19620439.
- ↑ Gosselin RC, Wu JR, Kottke-Marchant K, Peetz D, Christie DJ, Muth H; et al. (2012). "Evaluation of the Stratus® CS Acute Care™ D-dimer assay (DDMR) using the Stratus® CS STAT Fluorometric Analyzer: A prospective multisite study for exclusion of pulmonary embolism and deep vein thrombosis". Thromb Res. doi:10.1016/j.thromres.2011.12.015. PMID 22245223.
- ↑ Söhne M, Ten Wolde M, Boomsma F, Reitsma JB, Douketis JD, Büller HR (2006). "Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism". J Thromb Haemost. 4 (3): 552–6. doi:10.1111/j.1538-7836.2005.01752.x. PMID 16405522.
- ↑ Kiely DG, Kennedy NS, Pirzada O, Batchelor SA, Struthers AD, Lipworth BJ (2005). "Elevated levels of natriuretic peptides in patients with pulmonary thromboembolism". Respir Med. 99 (10): 1286–91. doi:10.1016/j.rmed.2005.02.029. PMID 16099151.
- ↑ Klok FA, Mos IC, Huisman MV (2008). "Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis". Am J Respir Crit Care Med. 178 (4): 425–30. doi:10.1164/rccm.200803-459OC. PMID 18556626.
- ↑ Horlander KT, Leeper KV (2003). "Troponin levels as a guide to treatment of pulmonary embolism". Curr Opin Pulm Med. 9 (5): 374–7. PMID 12904706.
- ↑ Konstantinides S, Geibel A, Olschewski M, Kasper W, Hruska N, Jäckle S; et al. (2002). "Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism". Circulation. 106 (10): 1263–8. PMID 12208803.
- ↑ Meyer T, Binder L, Hruska N, Luthe H, Buchwald AB (2000). "Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction". J Am Coll Cardiol. 36 (5): 1632–6. PMID 11079669.
- ↑ Müller-Bardorff M, Weidtmann B, Giannitsis E, Kurowski V, Katus HA (2002). "Release kinetics of cardiac troponin T in survivors of confirmed severe pulmonary embolism". Clin Chem. 48 (4): 673–5. PMID 11901075.
- ↑ Jiménez D, Díaz G, Molina J, Martí D, Del Rey J, García-Rull S; et al. (2008). "Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism". Eur Respir J. 31 (4): 847–53. doi:10.1183/09031936.00113307. PMID 18094010.