4 cavities myocardial strain: A useful tool to refine the early risk score of death in acute pulmonary embolism

Abstract

Introduction

In acute pulmonary embolism (PE), the early risk of death is currently evaluated based on European Society of Cardiology (ESC) risk score, including two-dimensional echocardiographic derived-parameters: right ventricular (RV) dimension, function and hemodynamics.

Objective

We hypothesized that additional parameters including the 4 cavities myocardial strain analysis could also be of interest in the stratification of early risk of death in PE.

Method

We retrospectively analyzed 477 patients hospitalized for acute EP. Patients were divided into 2 groups according to the early (in-hospital or at 30 day) risk of death as stated in the 2019 ESC Guidelines: group 1, with low or intermediate-low risk of death (n = 302) and group 2, with intermediate-high or high risk of death (n = 175). We determined usual 2D echocardiographic parameters used to define RV dysfunction in the ESC risk score: RV dilatation, pulmonary arterial pressure, TAPSE, S’, RV Fractionnal Area Change (FAC), end diastolic left ventricle (LV) diameter, right atrial (RA) area. In addition, we evaluated LV, left atrial (LA), RA and RV strain using transthoracic echocardiography (TTE) obtained at admission.

Results

Patients with intermediate-high or high risk of death were older, had more often a familial history of PE, stroke, and cognitive impairment (P < 0.05). Patients with intermediate-high or high risk of death had larger RV and RA, more severe RV and LV dysfunction and higher systolic pulmonary arterial pressure. Myocardial strain analyses demonstrated that patients with intermediate-high or high risk of death had significantly lower LV and RV strain, lower LA reservoir, conduit and contractile strain, lower RA reservoir and conduit strain (P < 0.05). Multivariate logistic regression analysis (excluding usual 2D echocardiographic parameters used to define RV dysfunction in the ESC risk score) found that RV free wall strain and RA conduit strain could in addition significantly predict the intermediate-high or high-risk group of death (Table 1).

Conclusion

RV and RA strain analysis are potentially interesting new tools in addition to conventional echocardiographic parameters to assess right cavities dysfunction and could contribute to predict short-term outcome in PE.