Pulmonary embolism biomarkers: Difference between revisions

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__NOTOC__
__NOTOC__
{| class="infobox" style="float:right;"
|-
| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br>
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{Pulmonary embolism}}
{{Pulmonary embolism}}
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]
==Overview==
==Overview==
Although the success of [[brain natriuretic peptide]] levels to diagnose  pulmonary embolism is limited due to the reduced sensitivity of the test,<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> elevated [[BNP]] and [[BNP|pro-BNP]] levels accurately predict [[right ventricular dysfunction]] and associated mortality, and are therefore useful prognostic markers. <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> The evaluation of [[troponin]] levels also serves as a useful prognostic marker to identify right ventricular 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> and mortality associated 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>
Although the usefulness of [[brain natriuretic peptide]] (BNP) concentrations to diagnose  pulmonary embolism (PE) is limited,<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> elevated [[BNP]] and [[BNP|pro-BNP]] levels are associated with [[right ventricular dysfunction]] and increased mortality, and are therefore useful prognostic markers.<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> The evaluation of [[troponin]] concentration also serves as a useful [[prognostic]] marker to identify [[myocardial]] [[necrosis]]<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> and [[mortality]] associated with [[acute]] PE.<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>
 
== Biomarkers ==
== Biomarkers ==
=== Brain Natriuretic Peptide (BNP) ===
=== Brain Natriuretic Peptide ([[BNP]]) ===
Patients with pulmonary embolism and [[Pulmonary embolism ventilation/perfusion scan|ventilation-perfusion mismatch]] have been shown to have elevated [[BNP]] levels,<ref name="pmid16099151">{{cite journal |author=Kiely DG, Kennedy NS, Pirzada O, Batchelor SA, Struthers AD, Lipworth BJ |title=Elevated levels of natriuretic peptides in patients with pulmonary thromboembolism |journal=[[Respiratory Medicine]] |volume=99 |issue=10 |pages=1286–91 |year=2005 |month=October |pmid=16099151 |doi=10.1016/j.rmed.2005.02.029 |url=http://linkinghub.elsevier.com/retrieve/pii/S0954-6111(05)00067-3 |accessdate=2012-05-01}}</ref> however 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.<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>
* [[BNP]] levels can be elevated among patients with PE.<ref name="pmid16099151">{{cite journal |author=Kiely DG, Kennedy NS, Pirzada O, Batchelor SA, Struthers AD, Lipworth BJ |title=Elevated levels of natriuretic peptides in patients with pulmonary thromboembolism |journal=[[Respiratory Medicine]] |volume=99 |issue=10 |pages=1286–91 |year=2005 |month=October |pmid=16099151 |doi=10.1016/j.rmed.2005.02.029 |url=http://linkinghub.elsevier.com/retrieve/pii/S0954-6111(05)00067-3 |accessdate=2012-05-01}}</ref> However, the routine assessment of [[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.<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>
   
   
In 2006 Sohne et al, demonstrated that the presence of elevated [[BNP]] levels at admission were associated with early fatal [[venous thromboembolism]] in hemodynamically stable patients with acute [[PE]]. This relationship appeared to be clinically insignificant when used as a guide to initiate early [[thrombolysis]] in this population.<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>
* In 2006 Sohne et al, demonstrated that the presence of elevated [[BNP]] levels at admission were associated with early fatal [[venous thromboembolism]] in [[hemodynamically]] stable patients with [[acute]] [[PE]]. This relationship appeared to be clinically insignificant when used as a guide to initiate early [[thrombolysis]] in this population.<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>
 
[[BNP]] and [[BNP|pro-BNP]] levels are beneficial 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> in fact, elevated [[BNP]] levels is associated with [[right ventricular dysfunction]] and associated mortality in the setting of a PE.<ref name="pmid18626627">{{cite journal |author=Cavallazzi R, Nair A, Vasu T, Marik PE |title=Natriuretic peptides in acute pulmonary embolism: a systematic review |journal=[[Intensive Care Medicine]] |volume=34 |issue=12 |pages=2147–56 |year=2008 |month=December |pmid=18626627 |doi=10.1007/s00134-008-1214-5 |url=http://dx.doi.org/10.1007/s00134-008-1214-5 |accessdate=2012-05-01}}</ref><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=[[American Journal of Respiratory and Critical Care Medicine]] |volume=178 |issue=4 |pages=425–30 |year=2008 |month=August |pmid=18556626 |doi=10.1164/rccm.200803-459OC |url=http://ajrccm.atsjournals.org/cgi/pmidlookup?view=long&pmid=18556626 |accessdate=2012-05-01}}</ref><ref name="pmid19525265">{{cite journal |author=Lega JC, Lacasse Y, Lakhal L, Provencher S |title=Natriuretic peptides and troponins in pulmonary embolism: a meta-analysis |journal=[[Thorax]] |volume=64 |issue=10 |pages=869–75 |year=2009 |month=October |pmid=19525265 |doi=10.1136/thx.2008.110965 |url=http://thorax.bmj.com/cgi/pmidlookup?view=long&pmid=19525265 |accessdate=2012-05-01}}</ref>  The presence of [[right ventricular dysfunction]] is one of the criteria used to classify a PE as submassive or intermediate risk.<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>


The following values are considered a marker of [[right ventricular dysfunction]]:<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
* [[BNP]] and [[BNP|pro-BNP]] levels are beneficial 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> in fact, elevated [[BNP]] levels is associated with [[right ventricular dysfunction]] and associated [[mortality]] in the setting of a PE.<ref name="pmid18626627">{{cite journal |author=Cavallazzi R, Nair A, Vasu T, Marik PE |title=Natriuretic peptides in acute pulmonary embolism: a systematic review |journal=[[Intensive Care Medicine]] |volume=34 |issue=12 |pages=2147–56 |year=2008 |month=December |pmid=18626627 |doi=10.1007/s00134-008-1214-5 |url=http://dx.doi.org/10.1007/s00134-008-1214-5 |accessdate=2012-05-01}}</ref><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=[[American Journal of Respiratory and Critical Care Medicine]] |volume=178 |issue=4 |pages=425–30 |year=2008 |month=August |pmid=18556626 |doi=10.1164/rccm.200803-459OC |url=http://ajrccm.atsjournals.org/cgi/pmidlookup?view=long&pmid=18556626 |accessdate=2012-05-01}}</ref><ref name="pmid19525265">{{cite journal |author=Lega JC, Lacasse Y, Lakhal L, Provencher S |title=Natriuretic peptides and troponins in pulmonary embolism: a meta-analysis |journal=[[Thorax]] |volume=64 |issue=10 |pages=869–75 |year=2009 |month=October |pmid=19525265 |doi=10.1136/thx.2008.110965 |url=http://thorax.bmj.com/cgi/pmidlookup?view=long&pmid=19525265 |accessdate=2012-05-01}}</ref>  The presence of [[right ventricular dysfunction]] is one of the criteria used to classify a PE as submassive or intermediate risk.<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>


*[[BNP]] > 90 pg/mL
* The following values are considered a marker of [[right ventricular dysfunction]]:<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
*[[N-terminal pro-BNP]] >500 pg/mL
** [[BNP]] > 90 pg/mL
** [[N-terminal pro-BNP]] >500 pg/mL


=== Troponin ===
=== Troponin ===
* Measurement of [[troponin]] subtype levels, particularly [[troponin I]] and [[troponin T]], may be of value 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>  
* Measurement of [[troponin]] subtype levels, particularly [[troponin I]] and [[troponin T]], may be of value 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>  


* [[Troponin|Serum troponin]] concentrations can be elevated in patients with an acute PE, however its use in diagnosing a PE is very limited. The role of [[troponin]] in PE is to risk stratify patients and to optimize management strategies.  In fact, elevated [[troponin]]s are a marker of myocardial [[necrosis]], one of the criteria used to classify PE into submassive or intermediate risk. [[Myocardial necrosis]] in [[PE]] is defined as the presence of:<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
* [[Troponin|Serum troponin]] concentrations can be elevated in patients with an [[acute]] PE, however its use in diagnosing a PE is very limited. The role of [[troponin]] in PE is to risk stratify patients and to optimize management strategies.  In fact, elevated [[troponin]]s are a marker of [[myocardial]] [[necrosis]], one of the criteria used to classify PE into submassive or intermediate risk. [[Myocardial necrosis]] in [[PE]] is defined as the presence of:<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation| year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref><ref name="pmid8914880">{{cite journal |author=Cannon CP, Goldhaber SZ |title=Cardiovascular risk stratification of pulmonary embolism |journal=Am. J. Cardiol. |volume=78 |issue=10 |pages=1149–51 |year=1996 |month=November |pmid=8914880 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914996005802 |accessdate=2011-12-21}}</ref>
**Elevation of [[troponin I]] (>0.4 ng/mL), OR
**Elevation of [[troponin I]] (>0.4 ng/mL), OR
**Elevation of [[troponin T]] (>0.1 ng/mL)
**Elevation of [[troponin T]] (>0.1 ng/mL)


* Troponins are also a prognostic marker of [[RV dysfunction]] in patients with a confirmed PE.<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 have a significant amount of segmental defects on [[Pulmonary embolism ventilation/perfusion scan|V/Q scan]].<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><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>  
* [[Troponin]]s are also a [[prognostic]] marker of [[right ventricular dysfunction]] in patients with a confirmed PE.<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 [[right ventricular dysfunction]] who have a significant amount of segmental defects on [[Pulmonary embolism ventilation/perfusion scan|V/Q scan]].<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><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>  


* When compared to patients with [[myocardial infarction]] (MI), the variation in [[troponin]] concentration among patients with acute PE follow a different pattern.<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> A study on 9 patients with elevated [[troponin]]s revealed that elevated troponins have a lower peak levels and remain detectable for a shorter period of time compared to that in acute MI.<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>
* When compared to patients with [[myocardial infarction]] ([[MI]]), the variation in [[troponin]] concentration among patients with [[acute]] PE follow a different pattern.<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 surught ventricularivors 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> A study on 9 patients with elevated [[troponin]]s revealed that elevation in [[troponin]]s has a lower peak levels and remains detectable for a shorter period of time compared to that in [[acute]] [[MI]].<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 surught ventricularivors 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>


==References==
==References==
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Latest revision as of 23:53, 29 July 2020
Resident
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]

Overview

Although the usefulness of brain natriuretic peptide (BNP) concentrations to diagnose pulmonary embolism (PE) is limited,[1] elevated BNP and pro-BNP levels are associated with right ventricular dysfunction and increased mortality, and are therefore useful prognostic markers.[2] The evaluation of troponin concentration also serves as a useful prognostic marker to identify myocardial necrosis[3][4] and mortality associated with acute PE.[5]

Biomarkers

Brain Natriuretic Peptide (BNP)

  • BNP levels can be elevated among patients with PE.[6] However, the routine assessment of 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 were associated with early fatal venous thromboembolism in hemodynamically stable patients with acute PE. This relationship appeared to be clinically insignificant when used as a guide to initiate early thrombolysis in this population.[1]

Troponin

  • When compared to patients with myocardial infarction (MI), the variation in troponin concentration among patients with acute PE follow a different pattern.[16] A study on 9 patients with elevated troponins revealed that elevation in troponins has a lower peak levels and remains detectable for a shorter period of time compared to that in acute MI.[16]

References

  1. ↑ 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. ↑ 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. ↑ 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. ↑ 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)
  5. ↑ 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.
  6. ↑ 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)
  7. ↑ 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. ↑ 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)
  9. ↑ 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)
  10. ↑ 10.0 10.1 10.2 Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
  11. ↑ 11.0 11.1 11.2 Cannon CP, Goldhaber SZ (1996). "Cardiovascular risk stratification of pulmonary embolism". Am. J. Cardiol. 78 (10): 1149–51. PMID 8914880. Retrieved 2011-12-21. Unknown parameter |month= ignored (help)
  12. ↑ 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)
  13. ↑ 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)
  14. ↑ 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)
  15. ↑ 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)
  16. ↑ 16.0 16.1 Müller-Bardorff M, Weidtmann B, Giannitsis E, Kurowski V, Katus HA (2002). "Release kinetics of cardiac troponin T in surught ventricularivors of confirmed severe pulmonary embolism". Clinical Chemistry. 48 (4): 673–5. PMID 11901075. Retrieved 2012-05-02.

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