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Original Research: PULMONARY EMBOLISM |

Troponin-Based Risk Stratification of Patients With Acute Nonmassive Pulmonary Embolism: Systematic Review and Metaanalysis

David Jiménez, MD; Fernando Uresandi, MD; Remedios Otero, MD; José Luis Lobo, MD; Manuel Monreal, MD; David Martí, MD; Javier Zamora, MD; Alfonso Muriel, MD; Drahomir Aujesky, MD; Roger D. Yusen, MD, FCCP
Author and Funding Information

Affiliations: From the Respiratory Department (Dr. Jiménez), the Cardiology Department (Dr. Martí), and the Biostatistics Unit (Drs. Zamora and Muriel), Ramón y Cajal Hospital, Madrid, Spain; the Respiratory Department (Dr. Uresandi), Cruces Hospital, Bilbao, Spain; the Respiratory Department (Dr. Otero), Virgen del Rocío Hospital, Sevilla, Spain; the Respiratory Department (Dr. Lobo), Txagorritxu Hospital, Vitoria, Spain; the Medicine Department (Dr. Monreal), Germans Trias i Pujol Hospital, Barcelona, Spain; the Division of General Internal Medicine (Dr. Aujesky), University of Lausanne, Lausanne, Switzerland; and the Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences (Dr. Yusen), Washington University School of Medicine, St. Louis, MO.

Correspondence to: David Jiménez, MD, Respiratory Department, Ramón y Cajal Hospital, Colmenar Rd, Kilometer 9.100, 28034 Madrid, Spain; e-mail: djc_69_98@yahoo.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

For editorial comment see page 952


© 2009 American College of Chest Physicians


Chest. 2009;136(4):974-982. doi:10.1378/chest.09-0608
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Background:  Controversy exists regarding the usefulness of troponin testing for the risk stratification of patients with acute pulmonary embolism (PE). We conducted an updated systematic review and a metaanalysis of troponin-based risk stratification of normotensive patients with acute symptomatic PE. The sources of our data were publications listed in Medline and Embase from 1980 through April 2008 and a review of cited references in those publications.

Methods:  We included all studies that estimated the relation between troponin levels and the incidence of all-cause mortality in normotensive patients with acute symptomatic PE. Two reviewers independently abstracted data and assessed study quality. From the literature search, 596 publications were screened. Nine studies that consisted of 1,366 normotensive patients with acute symptomatic PE were deemed eligible. Pooled results showed that elevated troponin levels were associated with a 4.26-fold increased odds of overall mortality (95% CI, 2.13 to 8.50; heterogeneity χ2 = 12.64; degrees of freedom = 8; p = 0.125). Summary receiver operating characteristic curve analysis showed a relationship between the sensitivity and specificity of troponin levels to predict overall mortality (Spearman rank correlation coefficient = 0.68; p = 0.046). Pooled likelihood ratios (LRs) were not extreme (negative LR, 0.59 [95% CI, 0.39 to 0.88]; positive LR, 2.26 [95% CI, 1.66 to 3.07]). The Begg rank correlation method did not detect evidence of publication bias.

Conclusions:  The results of this metaanalysis indicate that elevated troponin levels do not adequately discern normotensive patients with acute symptomatic PE who are at high risk for death from those who are at low risk for death.

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