CHEST Guidelines-Are-We-Correctly-Defining-Intermediate-Risk-Pulmon

Are-We-Correctly-Defining-Intermediate-Risk-Pulmon

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The correspondence by Drs. Mark A. Bradford and Harrison W. Farber, published in the journal CHEST, raises questions about the current definition of intermediate-risk pulmonary embolism (PE) based on the 2008 European Society of Cardiology guidelines. These guidelines estimate the early-mortality risk for intermediate-risk PE at 3% to 15%. The authors argue that recent studies, including the Pulmonary Embolism Thrombolysis (PEITHO) trial, challenge the validity of the current risk stratification methods, which rely on echocardiography and cardiac biomarkers such as troponin levels and brain natriuretic peptide (BNP).<br /><br />Several meta-analyses have contested the predictive value of these methods. A 2004 meta-analysis found that echocardiography had a low positive predictive value for PE-related in-hospital mortality among normotensive patients. Another analysis in 2007 linked elevated troponin levels to increased mortality but noted a low positive predictive value. Additionally, a 2008 analysis showed that elevated BNP levels were associated with in-hospital mortality, but the broad confidence intervals highlighted the need for further study.<br /><br />The authors note that the PEITHO trial, which explored fibrinolytic therapy for intermediate-risk PE, revealed an unexpected early mortality rate of only 1.8% in the placebo group, casting further doubt on the existing risk definitions. They suggest that without a clear understanding of the true risk level of intermediate-risk groups, incorporating transesophageal echocardiography into treatment algorithms remains uncertain.<br /><br />Mark A. Bradford and Harrison W. Farber hail from the Pulmonary Center at Boston University School of Medicine and indicated no potential conflicts of interest related to the discussion in their correspondence.

Keywords

intermediate-risk pulmonary embolism

European Society of Cardiology guidelines

early-mortality risk

PEITHO trial

echocardiography

cardiac biomarkers

troponin levels

brain natriuretic peptide

risk stratification

fibrinolytic therapy