Advertisement

Prognostic Value of Plasma Lactate Levels Among Patients With Acute Pulmonary Embolism: The Thrombo-Embolism Lactate Outcome Study

      Study objective

      We investigate the prognostic value of plasma lactate levels in patients with acute pulmonary embolism.

      Methods

      We studied adult patients with symptomatic, objectively confirmed pulmonary embolism presenting to a single emergency department. Plasma lactate and troponin I levels were tested at presentation. We considered lactate values greater than or equal to 2 mmol/L and troponin I values greater than or equal to 0.10 ng/mL to be abnormal. Right-sided ventricular dysfunction was assessed by echocardiography. Primary endpoint was all-cause death occurring on or before 30 days after presentation. Secondary endpoints were the composite of all-cause death and clinical deterioration (defined as progression to shock, mechanical ventilation, or cardiopulmonary resuscitation) and death caused by pulmonary embolism. We tested the association between lactate level greater than or equal to 2 mmol/L and the endpoints using Cox proportional hazards regression analysis.

      Results

      Of the 270 patients included in the study, the mean age was 73 years (SD 12.7 years) and 151 (55.9%) were women. Twelve patients (4.4%) showed shock or hypotension (shock or systolic arterial pressure <100 mm Hg) at presentation, 109 (40.4%) had right-sided ventricular dysfunction, 93 (34.4%) showed troponin I level greater than or equal to 0.10 ng/mL, and 81 (30%) showed lactate level greater than or equal to 2 mmol/L. Seventeen patients (6.3%) died, 12 (4.4%) because of pulmonary embolism, and 37 (13.7%) reached the composite endpoint. Patients with lactate level greater than or equal to 2 mmol/L showed higher mortality (17.3%; 95% confidence interval [CI] 11.9% to 20%) than patients with a lower level (1.6%; 95% CI 0.8% to 1.9%). Plasma lactate level was associated with all-cause death (hazard ratio 11.67; 95% CI 3.32 to 41.03) and the composite endpoint (hazard ratio 8.14; 95% CI 3.83 to 17.34) independent of shock or hypotension, right-sided ventricular dysfunction, or elevation of troponin I values.

      Conclusion

      Patients with pulmonary embolism and elevated plasma lactate level are at high risk of death and adverse outcome, independent of shock or hypotension, or right-sided ventricular dysfunction or injury markers.
      To read this article in full you will need to make a payment
      ACEP Member Login
      ACEP Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Pulido T.
        • Aranda A.
        • Zevallos M.A.
        • et al.
        Pulmonary embolism as a cause of death in patients with heart disease: an autopsy study.
        Chest. 2006; 129: 1282-1287
        • Burge A.J.
        • Freeman K.D.
        • Klapper P.J.
        • et al.
        Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era.
        Clin Radiol. 2008; 63: 381-386
        • Torbicki A.
        • Perrier A.
        • Konstantinides S.
        • et al.
        Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology.
        Eur Heart J. 2008; 29: 2276-2315
        • Grifoni S.
        • Olivotto I.
        • Cecchini P.
        • et al.
        Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction.
        Circulation. 2000; 101: 2817-2822
        • Becattini C.
        • Vedovati M.C.
        • Agnelli G.
        Prognostic value of troponins in acute pulmonary embolism: a meta-analysis.
        Circulation. 2007; 116: 427-433
        • Kucher N.
        • Goldhaber S.Z.
        Cardiac biomarkers for risk stratification of patients with acute pulmonary embolism.
        Circulation. 2003; 108: 2191-2194
        • Kline J.A.
        • Zeitouni R.
        • Marchick M.R.
        • et al.
        Comparison of 8 biomarkers for prediction of right ventricular hypokinesis 6 months after submassive pulmonary embolism.
        Am Heart J. 2008; 156: 308-314
        • Binder L.
        • Pieske B.
        • Olschewski M.
        • et al.
        N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism.
        Circulation. 2005; 112: 1573-1579
        • Shapiro N.I.
        • Trzeciak S.
        • Hollander J.E.
        • et al.
        A prospective, multicenter derivation of a biomarker panel to assess risk of organ dysfunction, shock, and death in emergency department patients with suspected sepsis.
        Crit Care Med. 2009; 37: 96-104
        • Vanni S.
        • Socci F.
        • Pepe G.
        • et al.
        High plasma lactate levels are associated with increased risk of in-hospital mortality in patients with pulmonary embolism.
        Acad Emerg Med. 2011; 18: 830-835
        • Vanni S.
        • Polidori G.
        • Vergara R.
        • et al.
        Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure.
        Am J Med. 2009; 122: 257-264
        • Grifoni S.
        • Vanni S.
        • Magazzini S.
        • et al.
        Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events.
        Arch Intern Med. 2006; 166: 2151-2156
        • Hyers T.M.
        • Agnelli G.
        • Hull R.D.
        • et al.
        Sixth ACCP Consensus Conference on antithrombotic therapy.
        Chest. 2001; 119: 176S-193S
        • Karon B.S.
        • Scott R.
        • Burritt M.F.
        • et al.
        Comparison of lactate values between point-of-care and central laboratory analyzers.
        Am J Clin Pathol. 2007; 128: 168-171
        • Vergara I.A.
        • Norambuena T.
        • Ferrada E.
        • et al.
        StAR: a simple tool for the statistical comparison of ROC curves.
        BMC Bioinformatics. 2008; 9: 265
        • Jiménez D.
        • Aujesky D.
        • Moores L.
        • et al.
        Simplification of the Pulmonary Embolism Severity Index for prognostication in patients with acute symptomatic pulmonary embolism.
        Arch Intern Med. 2010; 170: 1383-1389
        • Spirk D.
        • Aujesky D.
        • Husmann M.
        • et al.
        Cardiac troponin testing and the simplified Pulmonary Embolism Severity Index.
        Thromb Haemost. 2011; 106: 978-984
        • Stein P.D.
        • Matta F.
        • Janjua M.
        • et al.
        Outcome in stable patients with acute pulmonary embolism who had right ventricular enlargement and/or elevated levels of troponin I.
        Am J Cardiol. 2010; 106: 558-563
        • Rivers E.
        • Nguyen B.
        • Havstad S.
        • et al.
        Early goal-directed therapy in the treatment of severe sepsis and septic shock.
        N Engl J Med. 2001; 345: 1368-1377
        • Lavery R.F.
        • Livingston D.H.
        • Tortella B.J.
        • et al.
        The utility of venous lactate to triage injured patients in the trauma center.
        J Am Coll Surg. 2000; 190: 656-664
        • Evans T.R.
        • Stein R.C.
        • Ford H.T.
        • et al.
        Lactic acidosis.
        Cancer. 1992; 69: 453-456
        • Scalea T.M.
        • Hartnett R.W.
        • Duncan A.O.
        • et al.
        Central venous oxygen saturation: a useful clinical tool in trauma patients.
        J Trauma. 1990; 30: 1539-1543
        • Wan S.
        • Quinlan D.J.
        • Agnelli G.
        • et al.
        Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials.
        Circulation. 2004; 110: 744-749
        • Konstantinides S.
        • Geibel A.
        • Heusel G.
        • et al.
        Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism.
        N Engl J Med. 2002; 347: 1143-1150
        • PEITHO Investigators
        Single-bolus tenecteplase plus heparin compared with heparin alone for normotensive patients with acute pulmonary embolism who have evidence of right ventricular dysfunction and myocardial injury: Rationale and design of the Pulmonary Embolism Thrombolysis (PEITHO) trial.
        Am Heart J. 2012; 163: 33-38
        • Lankeit M.
        • Jiménez D.
        • Kostrubiec M.
        • et al.
        Predictive value of the high-sensitivity troponin T assay and the simplified Pulmonary Embolism Severity Index in hemodynamically stable patients with acute pulmonary embolism: a prospective validation study.
        Circulation. 2011; 124: 2716-2724