Cardiac biomarkers in prognostic stratification of patients with pulmonary thrombembolism

  • Nina Kmet-Lunaček
  • Andrej Pernat
  • Hugon Možina
Keywords: pulmonary embolism, right ventricular dysfunction, prognosis, cardiac biomarkers


Background: Pulmonary thrombembolism represents a spectrum of clinical syndromes ranging from small embolism presenting with dyspnea alone to massive thrombembolism causing shock or cardiac arrest. Majority of patients with pulmonary thrombembolism present with normal blood pressure, however, some may rapidly deteriorate despite therapeutic anticoagulation with heparine. Identification of such patients by risk stratification is of utmost importance for the care of pulmonary thrombembolism. It has been known for several years that a strong corellation exists between the prognosis of acute pulmonary thrombembolism and the degree of right ventricular dysfunction. Recently, some cardiac biomarkers have shown to be a promising predictive factor in evaluating right ventricular dysfunction and consequently establishing the prognosis of the clinical course in submassive and massive pulmonary thrombembolism. In the article the most important recent studies are represented confirming the important role of cardiac biomarkers in connection with prognosis in acute pulmonary thrombembolism. The most important are troponins, B-type of natriuretic peptide (BNP) with its pro-types and myoglobin.

Conclusions: Elevated levels of troponins, in combination with echocardiographic signs of right ventricular dysfunction, are powerful predictors of adverse events and early mortality in normotensive patients with pulmonary thrombembolism. Normal or only slightly elevated levels of brain natriuretic peptides identify favourable prognosis in patients with pulmonary thrombembolism.


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Možina H. Pljučna embolija. In: Kocijančič A, Mrevlje F, Štajer D. Interna medicina. Ljubljana: DZS; 2005. p. 276–83.

Ribeiro A, Lindmarker P, Juhlin Dannfelt A, Johnsson H, Jorefeldt L. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J 1997; 134: 479–87.

Kucher N, Goldhaber SZ. Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism. Circulation 2003; 108: 2191–4.

Prusczyk P, Kostrubiec, Bochowicz A, Styczynski G, Szulc M, Kurzyna M, et al. N-terminal pro brain natriuretic peptide in patients with acute pulmonary embolism. Eur Respir J 2003; 22: 649–53.

Prusczyk P, Bochowicz A, Kostrubiec M, Trobicki A, Szulc M, Gruba H, et al. Myoglobin stratifies short-term risk in acute major pulmonary embolism. Clinica Chimica Acta 2003; 338: 53–6.

Wood KE. Major pulmonary embolism. Review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002; 121: 877–905.

Taylor RR, Covell JW, Sonnenblick EH, Taylor RR, Covell JW, Ross J Jr. Dependence of ventricular distensibility on filling of the opposite ventricle. Am J Physiol 1967; 213: 711–8.

Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H. Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 1997; 77: 346–9.

Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation 2004; 110: 3276–80.

Peternel P. Dejavniki tveganja za nastanek venske tromboze. Medicinski razgledi 1998; 39 Suppl 2; 3–8.

Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386–9.

Urokinase Pulmonary Embolism Trial. Phase 1 results: a cooperative study. JAMA 1970; 214: 2163–72.

Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, et al. Management strategies and determinants of outcome in acute major pulmonary embolism (MAPPET): results of a multicenter registry. J Am Coll Cardiol 1997; 30: 1165–71.

Jerjes Sanchez C, Ramirez-Rivera A, de Lourdes Garcia M, et al. Stroeptokinase and heparin versus heparin alone in massive pulmonary embolism: A randomized controlled trial. J Thromb Thrombolysis 1995; 2: 227–9.

Task Force on Pulmonary Embolism, European Society of Cardiology. Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J 2000; 21: 1301–36.

Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher. Arch Intern Med 2005; 165: 1777–81.

Come PC. Echocardiographic evaluation of pulmonary embolism and its response to therapeutic interventions. Chest 1992; 101 Suppl 4: 151S–62S.

Gibson NS, Sohne M, Buller HR. Prognostic value of echocardiography and spiral computed tomography in patients with pulmonary embolism. Curr Opin Pulm Med 2005; 11: 380–4.

Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser K, Rauber K, et al. Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism. Circulation 199; 96: 882–8.

Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus Alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002; 34: 1143–50.

Thabut G, Thabut D, Myers RP, et al. Thrombolytic therapy of pulmonary embolism: a meta-analysis. J Am Coll Cardiol 2002; 40: 1660–7.

Roongsritong C, Warraich I, Bradley C. Common causes of troponin elevations in the absence of acute myocardial infarction. Chest 2004; 125: 1877–84.

Kreit JW. The impact of right ventricular dysfunction on the prognosis and therapy of normotensive patients with pulmonary embolism. Chest 2004; 125: 1539–45.

Meyer T, Binder L, Hruska N, Luthe H, Buchwald AB. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol 2000; 36: 1632–6.

Giannitis E, Mueller-Baerdorff M, Kurowski V, Weidtmann B, Wiegand U, Kampann M, et al. Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism. Circulation 2000; 102: 211–7.

Prusczyk P, Bochowicz A, Trobicki A, Szulc M, Kurzyna M, Fijalkovska A, et al. Cardiac troponin T monitoring indetifies highrisk group of normotensive patients with acute pulmonary embolism. Chest 2003; 123: 1947–52.

Dieter RS, Ernst E, Ende DJ, Stein HJ. Diagnostic utility of cardiac troponin I levels in patients with suspected pulmonary embolism. Angiology 2002; 53: 583–5.

Yalamanchili K, Sukhija R, Aronow WS, Sinha N, Fleisher GA, Lehrman SG. Prevalence of increased troponin I levels in patients with and without acute pulmonary embolism and relation of increased cardiac troponin I levels with in hospital mortality in patients with acute pulmonary embolism. Am J Cardiol 2004; 93: 263–4.

La Vecchia L, Ottani F, Favero L, Sapadaro GL, Rubboli A, Boanno C, et al. Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism. Heart 2004; 90: 633–7.

Scridon T, Scridon C, Skali H, Alvarez A, Goldhaber SZ, Solomon SD. Prognostic significance of troponin elevation and right ventricular enlargement in acute pulmonary embolism. Am J Cardiol 2005; 96: 303–5.

Douketis JD, Leeuwenkamp O, Grobara P, Johnston M, Söhne M, Ten Wolde M, et al. The incidence and prognostic significance of elevated cardiac troponin in patients with submassive pulmonary embolism. J Thromb Haemost. 2005; 3: 508–13.

Konstantinides S, Geibel A, Olschewski M, Kasper W, Hruska N, Jaeckle S, et al. Importance of cardiac Troponins I and T in Risk Stratification of Patients With Acute Pulmonary Embolism. Circulation 2002; 106: 1263–8.

Kucher N, Wallmann D, Carone A, Windecker S, Meier B, Hess MO. Incremental prognostic value of troponin I and echocardiography in patients with acute pulmonary embolism. European Heart Journal 2003; 24: 1651–6.

Mehta JN, Jani K, Khan IA. Clincal usefulness and prognostic value of elevated cardiac troponin I levels in acute pulmonary embolism. Am Heart J 2003; 145: 821–5.

Gegenhuber A, Mueller T, Firlinger F, Lenz K, Poelz W, Haltmayer M. Time course of B-type natriuretic peptid (BNP) and N-terminal proBNP changes in patients with decompensated heart failure. Clinical Chemistry 2004; 50: 454–6.

Muders F, Kromer EP, Griese DP, Pfeifer M, Hense HW, Riegger GA. Evaluation of plasma natriuretic peptides as markers for left ventricular dysfunction. Am Heart J 1997; 134: 442–9.

Nagaya N, Nishikimi T, Satoh T, Kyotani S, Sakamaki F, et al. Plasma brain natriuretic peptid levels increasing proportion to the extent of right ventricular dysfunction in pulmonary hypertension. Circulation 2000; 102: 865–70.

Krueger S, Graf J, Merx M, Koch CK, Kunz D, Hanrath P, et al. Brain natriuretic peptid predicts right heart failure in patients with acute pulmonary embolism. Am Heart J 2004; 147: 60–5.

Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptid in acute pulmonary embolism. Circulation 2003; 107: 2545–7.

Tulevski II, Hirsch A, Sanson BJ. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Heart 2001; 86: 27–30.

Tulevski II, Hirsch A, Sanson BJ, Romkes H, Zwall van der EE, Veldhuisen van JD, et al. Increased brain natriuretic peptide as a marker for right ventricular dysfunction in acute pulmonary embolism. Thromb Haemost 2001; 86: 1193–6.

Sohne M, Wolde T, Boomsma M, Reitsma JB, Douketis JD, Buller HR. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost 2006; 4: 552–6.

Kostrubiec M, Prusczyk P, Bochowicz A, Pacho R, Szulc M, Kaczynska A, et al. Biomarker-based risk assessment model in acute pulmonary embolism. Eur Heart J 2005; 26: 166–72.

Ma JO, Cline DM. Emergency medicine manual. Boston: McGraw Hill; 2004.

Piazza G, Goldhaber SZ. Acute pulmonary embolism. Part II: treatment and prophylaxis. Circulation 2006; 114: 42–7.

Konstantinides S. Should thrombolytic therapy be used in patients with pulmonary embolism? Am J Cardiovasc Drugs 2004; 4: 69–74.

How to Cite
Kmet-Lunaček N, Pernat A, Možina H. Cardiac biomarkers in prognostic stratification of patients with pulmonary thrombembolism. ZdravVestn [Internet]. 1 [cited 17Jun.2019];75(9). Available from:
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