Pulmonary embolism biomarkers: Difference between revisions
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==Overview== | ==Overview== | ||
The assessment of [[brain natriuretic peptide]] levels to diagnose PE has limited use because of the reduced sensitivity. However, elevated [[BNP]] and [[BNP|pro-BNP]] levels accurately predict [[right ventricular dysfunction]] and associated mortality; hence, may used as a prognostic marker. | The assessment of [[brain natriuretic peptide]] levels to diagnose PE has limited use because of the reduced sensitivity.<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=[[Journal of Thrombosis and Haemostasis : JTH]] |volume=4 |issue=3 |pages=552–6 |year=2006|month=March |pmid=16405522 |doi=10.1111/j.1538-7836.2005.01752.x |url=http://dx.doi.org/10.1111/j.1538-7836.2005.01752.x|accessdate=2012-05-01}}</ref> However, elevated [[BNP]] and [[BNP|pro-BNP]] levels accurately predict [[right ventricular dysfunction]] and associated mortality; hence, may used as a prognostic marker. <ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294|doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-05-01}}</ref> Similarly, the evaluation of [[cTnT]] levels serves as an excellent prognostic marker to identify [[right ventricular dysfunction]] and/or detect minor myocardial injury.<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=[[Journal of the American College of Cardiology]]|volume=36 |issue=5 |pages=1632–6 |year=2000 |month=November |pmid=11079669 |doi=|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(00)00905-0 |accessdate=2012-05-02}}</ref><ref name="pmid12904706">{{cite journal |author=Horlander KT, Leeper KV |title=Troponin levels as a guide to treatment of pulmonary embolism |journal=[[Current Opinion in Pulmonary Medicine]] |volume=9 |issue=5 |pages=374–7 |year=2003|month=September |pmid=12904706 |doi=|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1070-5287&volume=9&issue=5&spage=374 |accessdate=2012-05-02}}</ref> However, it may not be used to predict all-cause mortality in stable patients presenting to the emergency dept with acute pulmonary embolism.<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> | ||
==Brain natriuretic peptide (BNP)== | ==Brain natriuretic peptide (BNP)== | ||
| Line 13: | Line 13: | ||
==Troponin== | ==Troponin== | ||
Assessment of [[troponin]] subtypes, particularly [[troponin I]] and [[troponin T]] may be valuable in patients presenting with [[chest pain|undifferentiated chest pain]] and/or [[dyspnea]].<ref name="pmid11784223">{{cite journal |author=Douketis JD, Crowther MA, Stanton EB, Ginsberg JS |title=Elevated cardiac troponin levels in patients with submassive pulmonary embolism |journal=[[Archives of Internal Medicine]] |volume=162 |issue=1 |pages=79–81 |year=2002 |month=January |pmid=11784223 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11784223 |accessdate=2012-05-02}}</ref> | |||
Despite the fact that [[troponin|serum troponin]] levels are elevated in majority of patients with acute PE, its use to diagnosis PE is very limited. However, it does remain one of the '''''strong prognostic marker''''' to identify [[RV dysfunction]] in patients with confirmed PE and a very useful tool to risk stratify and optimize the management strategies in such patients.<ref name="pmid10889133">{{cite journal |author=Giannitsis E, Müller-Bardorff M, Kurowski V, Weidtmann B, Wiegand U, Kampmann M, Katus HA |title=Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism |journal=[[Circulation]] |volume=102 |issue=2 |pages=211–7 |year=2000 |month=July |pmid=10889133 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=10889133 |accessdate=2012-05-02}}</ref><ref name="pmid12796172">{{cite journal |author=Pruszczyk P, Bochowicz A, Torbicki A, Szulc M, Kurzyna M, Fijałkowska A, Kuch-Wocial A |title=Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism |journal=[[Chest]] |volume=123 |issue=6 |pages=1947–52 |year=2003 |month=June |pmid=12796172 |doi= |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=12796172 |accessdate=2012-05-02}}</ref><ref name="pmid12208803">{{cite journal |author=Konstantinides S, Geibel A, Olschewski M, Kasper W, Hruska N, Jäckle S, Binder L |title=Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism |journal=[[Circulation]] |volume=106 |issue=10 |pages=1263–8 |year=2002 |month=September |pmid=12208803 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12208803 |accessdate=2012-05-02}}</ref> [[Troponin I]] specifically may be assessed to identify patients with [[RV dysfunction]] who had significantly more segmental defects on [[Pulmonary embolism ventilation/perfusion scan|lung scans]] <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=[[Journal of the American College of Cardiology]]|volume=36 |issue=5 |pages=1632–6 |year=2000 |month=November |pmid=11079669 |doi=|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(00)00905-0 |accessdate=2012-05-02}}</ref><ref name="pmid12904706">{{cite journal |author=Horlander KT, Leeper KV |title=Troponin levels as a guide to treatment of pulmonary embolism |journal=[[Current Opinion in Pulmonary Medicine]] |volume=9 |issue=5 |pages=374–7 |year=2003|month=September |pmid=12904706 |doi=|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1070-5287&volume=9&issue=5&spage=374 |accessdate=2012-05-02}}</ref> or to detect minor myocardial injury in patients presenting with acute PE.<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=[[Journal of the American College of Cardiology]] |volume=36 |issue=5 |pages=1632–6 |year=2000 |month=November |pmid=11079669 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(00)00905-0 |accessdate=2012-05-02}}</ref> | |||
Margit Müller-Bardorff et al, for the very first time, described the contrasting features of [[cTnT]] elevation in patients with angiographically defined [[PE]] and no underlying [[coronary artery disease]] in comparison to patients with [[MI|acute myocardial infarction]].<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=[[Clinical Chemistry]] |volume=48 |issue=4 |pages=673–5 |year=2002 |pmid=11901075 |doi= |url=http://www.clinchem.org/cgi/pmidlookup?view=long&pmid=11901075 |accessdate=2012-05-02}}</ref> Based on this study, the [[cTnT]] levels in patients with acute PE are summarized below and was found to have lower peak levels and remained detectable for a short period when compared to its levels in [[ST elevation myocardial infarction diagnosis|acute myocardial infarction]]. | |||
:*Peaked after a median of 10 h, | |||
:*Persisted at >0.1 μg/L (0.03 μg/L) for a median of 30 (35) h, and | |||
:*Remained detectable (>0.01 μg/L) for a median of only 40 h after admission. | |||
==References== | ==References== | ||
Revision as of 17:46, 2 May 2012
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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
The assessment of brain natriuretic peptide levels to diagnose PE has limited use because of the reduced sensitivity.[1] However, elevated BNP and pro-BNP levels accurately predict right ventricular dysfunction and associated mortality; hence, may used as a prognostic marker. [2] Similarly, the evaluation of cTnT levels serves as an excellent prognostic marker to identify right ventricular dysfunction and/or detect minor myocardial injury.[3][4] However, it may not be used to predict all-cause mortality in stable patients presenting to the emergency dept with acute pulmonary embolism.[5]
Brain natriuretic peptide (BNP)
Although, elevated BNP levels have been demonstrated in pulmonary embolism patients with ventilation-perfusion mismatch,[6] the associated usefulness of routinely assessing BNP levels to diagnose PE is not indicated as it is non-specific and has reduced sensitivity secondary to the presence of other etiologies which falsely elevate BNP levels in acute case scenarios.[1]
In 2006, Sohne et al, demonstrated that the presence of elevated BNP levels at admission was associated with early (fatal) recurrent venous thromboembolism in hemodynamically stable patients with acute PE. However, this relationship appeared to be clinically insignificant when used as a guide to initiate early thrombolysis in this population. Furthermore, the sensitivity and specificity of assessing BNP levels as a diagnostic test was found to be 60% and 62%, respectively.[1]
On the contrary, the benefit of using elevated BNP and pro-BNP levels as a prognostic marker[2] may be derived from the results of three meta-analysis[7][8][9] which demonstrated that elevated BNP levels accurately predicted right ventricular dysfunction and associated mortality.[8]
Troponin
Assessment of troponin subtypes, particularly troponin I and troponin T may be valuable in patients presenting with undifferentiated chest pain and/or dyspnea.[10]
Despite the fact that serum troponin levels are elevated in majority of patients with acute PE, its use to diagnosis PE is very limited. However, it does remain one of the strong prognostic marker to identify RV dysfunction in patients with confirmed PE and a very useful tool to risk stratify and optimize the management strategies in such patients.[11][12][13] Troponin I specifically may be assessed to identify patients with RV dysfunction who had significantly more segmental defects on lung scans [3][4] or to detect minor myocardial injury in patients presenting with acute PE.[3]
Margit Müller-Bardorff et al, for the very first time, described the contrasting features of cTnT elevation in patients with angiographically defined PE and no underlying coronary artery disease in comparison to patients with acute myocardial infarction.[14] Based on this study, the cTnT levels in patients with acute PE are summarized below and was found to have lower peak levels and remained detectable for a short period when compared to its levels in acute myocardial infarction.
- Peaked after a median of 10 h,
- Persisted at >0.1 μg/L (0.03 μg/L) for a median of 30 (35) h, and
- Remained detectable (>0.01 μg/L) for a median of only 40 h after admission.
References
- ↑ 1.0 1.1 1.2 Söhne M, Ten Wolde M, Boomsma F, Reitsma JB, Douketis JD, Büller HR (2006). "Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism". Journal of Thrombosis and Haemostasis : JTH. 4 (3): 552–6. doi:10.1111/j.1538-7836.2005.01752.x. PMID 16405522. Retrieved 2012-05-01. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Agnelli G, Becattini C (2010). "Acute pulmonary embolism". The New England Journal of Medicine. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294. Retrieved 2012-05-01. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 3.2 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". Journal of the American College of Cardiology. 36 (5): 1632–6. PMID 11079669. Retrieved 2012-05-02. Unknown parameter
|month=ignored (help) - ↑ 4.0 4.1 Horlander KT, Leeper KV (2003). "Troponin levels as a guide to treatment of pulmonary embolism". Current Opinion in Pulmonary Medicine. 9 (5): 374–7. PMID 12904706. Retrieved 2012-05-02. Unknown parameter
|month=ignored (help) - ↑ 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.
- ↑ Kiely DG, Kennedy NS, Pirzada O, Batchelor SA, Struthers AD, Lipworth BJ (2005). "Elevated levels of natriuretic peptides in patients with pulmonary thromboembolism". Respiratory Medicine. 99 (10): 1286–91. doi:10.1016/j.rmed.2005.02.029. PMID 16099151. Retrieved 2012-05-01. Unknown parameter
|month=ignored (help) - ↑ Cavallazzi R, Nair A, Vasu T, Marik PE (2008). "Natriuretic peptides in acute pulmonary embolism: a systematic review". Intensive Care Medicine. 34 (12): 2147–56. doi:10.1007/s00134-008-1214-5. PMID 18626627. Retrieved 2012-05-01. Unknown parameter
|month=ignored (help) - ↑ 8.0 8.1 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". American Journal of Respiratory and Critical Care Medicine. 178 (4): 425–30. doi:10.1164/rccm.200803-459OC. PMID 18556626. Retrieved 2012-05-01. Unknown parameter
|month=ignored (help) - ↑ Lega JC, Lacasse Y, Lakhal L, Provencher S (2009). "Natriuretic peptides and troponins in pulmonary embolism: a meta-analysis". Thorax. 64 (10): 869–75. doi:10.1136/thx.2008.110965. PMID 19525265. Retrieved 2012-05-01. Unknown parameter
|month=ignored (help) - ↑ Douketis JD, Crowther MA, Stanton EB, Ginsberg JS (2002). "Elevated cardiac troponin levels in patients with submassive pulmonary embolism". Archives of Internal Medicine. 162 (1): 79–81. PMID 11784223. Retrieved 2012-05-02. Unknown parameter
|month=ignored (help) - ↑ Giannitsis E, Müller-Bardorff M, Kurowski V, Weidtmann B, Wiegand U, Kampmann M, Katus HA (2000). "Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism". Circulation. 102 (2): 211–7. PMID 10889133. Retrieved 2012-05-02. Unknown parameter
|month=ignored (help) - ↑ Pruszczyk P, Bochowicz A, Torbicki A, Szulc M, Kurzyna M, Fijałkowska A, Kuch-Wocial A (2003). "Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism". Chest. 123 (6): 1947–52. PMID 12796172. Retrieved 2012-05-02. Unknown parameter
|month=ignored (help) - ↑ Konstantinides S, Geibel A, Olschewski M, Kasper W, Hruska N, Jäckle S, Binder L (2002). "Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism". Circulation. 106 (10): 1263–8. PMID 12208803. Retrieved 2012-05-02. Unknown parameter
|month=ignored (help) - ↑ 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". Clinical Chemistry. 48 (4): 673–5. PMID 11901075. Retrieved 2012-05-02.