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Correspondence |

Natriuretic Peptides for Assessing the Prognosis of Acute Pulmonary EmbolismResponse FREE TO VIEW

Giuseppe Lippi, MD; Giovanni Targher, MD
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Affiliations: Università degli Studi di Verona, Verona, Italy,  Boston, MA

Correspondence to: Giuseppe Lippi, MD, Sezione di Chimica Clinica, Dipartimento di Scienze Morfologico-Biomediche, Università degli Studi di Verona, Ospedale Policlinico G. B. Rossi, Piazzale Scuro, 10, 37134 Verona, Italy; e-mail: ulippi@tin.it



Chest. 2008;133(6):1531-1532. doi:10.1378/chest.08-0404
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We read with interest the recent article by Samuel Goldhaber in CHEST (February 2008),1 who concluded that the incorporation of cardiac biomarkers such as troponin and the rapid assessment of right ventricular (RV) size into the routine workup of patients with acute pulmonary embolism (APE) would help to predict the likelihood of adverse outcomes. We definitely agree with this conclusion, and we would like to make further observations.

Elevated levels of natriuretic peptides, especially the N-terminal-pro-brain natriuretic peptide (NT-proBNP), are frequently observed in the setting of APE, reflecting right heart strain.2 Their measurement is helpful and highly accurate in identifying low-risk APE patients, displaying a negative predictive value (NPV) for in-hospital death close to 99%.2Because of the short half-life of natriuretic peptides, particularly NT-proBNP, these biomarkers may also be helpful in serial monitoring and in gauging the success of different APE treatment regimens.3In fact, a treatment-induced drop in wedge pressure in patients with decompensated heart failure due to volume overload is often accompanied by a rapid drop in the levels of natriuretic peptides.4Tulevski et al5 recently showed that cardiac troponin T (cTnT) and NT-proBNP levels measured on hospital admission predicted all-cause mortality and APE-related deaths, whereas RV overload predicted only APE-related mortality. Interestingly, although RV overload showed a NPV of 100% for APE-related mortality, its predictive value was only 13%. In contrast, the positive predictive value of NT-proBNP and cTnT (in micrograms per liter) was 33%, without a marked decrease of the NPV (97%).5

The acknowledged limitations of echocardiography include its restricted availability on a 24-h basis every day of the year and the relatively high cost. Although further prospective studies are needed to establish whether a combination of the measurement of cTnT and NT-proBNP levels might provide faster and equally reliable prognostic information as that provided by echocardiography alone, preliminary data indicate that this possibility should be considered.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The author has no conflict of interest to disclose.

Goldhaber, SZ (2008) Assessing the prognosis of acute pulmonary embolism: tricks of the trade.Chest133,334-336. [PubMed] [CrossRef]
 
Kucher, N, Goldhaber, SZ Risk stratification of acute pulmonary embolism.Semin Thromb Hemost2006;32,838-847. [PubMed]
 
Kucher, N, Goldhaber, SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism.Circulation2003;108,2191-2194. [PubMed]
 
Daniels, LB, Maisel, AS Natriuretic peptides.J Am Coll Cardiol2007;50,2357-2368. [PubMed]
 
Tulevski, II, ten Wolde, M, van Veldhuisen, DJ, et al Combined utility of brain natriuretic peptide and cardiac troponin T may improve rapid triage and risk stratification in normotensive patients with pulmonary embolism.Int J Cardiol2007;116,161-166. [PubMed]
 
To the Editor:

I thank Lippi and Targher for their kind remarks about my editorial in CHEST (February 2008),1 which describes “tricks of the trade” for assessing pulmonary embolism prognosis. They raise two important questions: (1) Should measurement of natriuretic peptides such as brain natriuretic peptide or pro-brain natriuretic peptide be incorporated into routine prognostic assessment of acute pulmonary embolism? (2) Do brain natriuretic peptide levels provide clinically useful, complementary information above and beyond troponin measurement?

Troponin measurement has several advantages over natriuretic peptides. First, any elevation of troponin, even a “troponin leak,” carries a markedly increased adverse prognosis for survival over the ensuing 30 days. Second, troponin as a pulmonary embolism biomarker has been far more extensively studied than natriuretic peptides. Third, the normal range for natriuretic peptides and the level at which they indicate a poor prognosis for pulmonary embolism remain uncertain. Fourth, the negative predictive value for a normal troponin level is almost 100%. Therefore, it is hard to conceive how natriuretic peptides can yield incrementally useful clinical information to indicate a favorable prognosis. Fifth, dissecting the contribution of occult or overt concomitant heart failure to elevated natriuretic peptide levels in the presence of pulmonary embolism is difficult.

For now, we know that normal troponin levels indicate a likely excellent prognosis. I hope that some day soon, we will be able to use the combination of elevated troponin levels plus elevated natriuretic peptide levels as an indicator of an especially ominous prognosis. However, that day has not yet arrived. Therefore, routine measurement of natriuretic peptides is not quite ready for prime time when assessing the prognosis of a patient with acute pulmonary embolism.

References
Goldhaber, SZ Assessing the prognosis of acute pulmonary embolism: tricks of the trade.Chest2008;133,334-336. [PubMed] [CrossRef]
 

Figures

Tables

References

Goldhaber, SZ (2008) Assessing the prognosis of acute pulmonary embolism: tricks of the trade.Chest133,334-336. [PubMed] [CrossRef]
 
Kucher, N, Goldhaber, SZ Risk stratification of acute pulmonary embolism.Semin Thromb Hemost2006;32,838-847. [PubMed]
 
Kucher, N, Goldhaber, SZ Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism.Circulation2003;108,2191-2194. [PubMed]
 
Daniels, LB, Maisel, AS Natriuretic peptides.J Am Coll Cardiol2007;50,2357-2368. [PubMed]
 
Tulevski, II, ten Wolde, M, van Veldhuisen, DJ, et al Combined utility of brain natriuretic peptide and cardiac troponin T may improve rapid triage and risk stratification in normotensive patients with pulmonary embolism.Int J Cardiol2007;116,161-166. [PubMed]
 
Goldhaber, SZ Assessing the prognosis of acute pulmonary embolism: tricks of the trade.Chest2008;133,334-336. [PubMed] [CrossRef]
 
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