Decision for aggressive therapy in acute pulmonary embolism: implication of elevated troponin T.

BACKGROUND: Elevated cardiac troponin T (cTnT) has been described in the setting of acute pulmonary embolism (PE) earlier, though currently it has no implication on the therapy in this setting. The protocol established in our institution recommends the use of fibrinolytic therapy as first-line therapy in these patients only when cTnT is elevated. This analysis was performed to evaluate the safety of this regimen in regard to 30-day mortality, morbidity and complications. METHODS AND
RESULTS: A total of 192 consecutive patients with confirmed PE, presenting at our institution during 2000-2005, were recruited. Right ventricular function was determined echocardiographically. CTnT was determined in all patients on admission. Patients without elevated cTnT were treated with anticoagulation alone, while patients with a TnT level above 0.1 ng/mL PE could be treated with thrombolysis on the discretion of the physician in charge. On day 30, cTnT elevation was associated with a higher mortality (P = 0.009). Moreover, in patients with intermediate-risk PE that were cTnT negative anticoagulation alone was safe showing a 30-day mortality of 1.8%, similar to low-risk PE (2.0%). In contrast to this patients with intermediate-risk PE with cTnT elevation showed a mortality rate of 20.8%, which was significantly higher (P < 0.001).
CONCLUSIONS: In patients with intermediate-risk PE without elevated cTnT, anticoagulation alone seems to be a safe regimen. The midterm prognosis of these patients is as good as the prognosis of patients with low-risk PE. In this cohort of patients with PE, beginning with a more conservative treatment strategy per se did not lead to an unfavourable outcome.