Incremental prognostic value of echocardiographic markers of right ventricular function in acute pulmonary embolism: an individual patient data analysis

Background

Right ventricular (RV) dysfunction is a major determinant of early mortality in acute pulmonary embolism (PE). Among parameters at echocardiography,tricuspid annular plane systolic excursion (TAPSE) reflects RV systolic function, whereas systolic pulmonary artery pressure (PASP) estimates RV afterload. The TAPSE/PASP ratio, a surrogate of RV–pulmonary artery coupling, has been proposed as a prognostic marker, but its incremental value remains uncertain.

Purpose

To evaluate the prognostic performance of TAPSE/PASP in acute PE and its incremental value beyond TAPSE and clinical risk stratification.

Methods

We performed an individual patient data meta-analysis including 16 observational studies including patients with confirmed acute PE (PROSPERO CRD4202238420). Studies reporting both TAPSE and PASP were included in the present analysis. The primary outcome was short-term all-cause mortality (in-hospital or within 30 days). TAPSE/PASP, TAPSE and PASP were analyzed as continuous variables using generalized linear mixed-effects models with random intercept for study. Discrimination was assessed by area under the curve (AUC). A sensitivity analysis was performed in hemodynamically stable patients with simplified Pulmonary Embolism Severity Index (sPESI) ≥1.

Results

A total of 2,682 patients (four studies) were included (51.3% women); 43.9% had sPESI ≥1 and 212 were hemodynamically unstable. Short-term mortality occurred in 201 patients (7.5%). TAPSE/PASP was associated with mortality (OR 0.25 per 0.1 increase; 95% CI 0.13–0.49), consistently after adjustment for hemodynamic instability (adjusted OR 0.44; 95% CI 0.23–0.85) and for sPESI (OR 0.41; 95% CI 0.21–0.79). The association was not confirmed in intermediate-risk patients (OR 0.79; 95% CI 0.40–1.57).

TAPSE values were independently associated with mortality (OR 0.93 per 1-mm increase; 95% CI 0.90–0.95), whereas PASP was not. When added separately to sPESI, TAPSE improved discrimination (AUC 0.707 vs 0.669; ΔAUC +0.038, p<0.001), whereas TAPSE/PASP yielded only a modest increase (AUC 0.690; ΔAUC +0.021, p=0.028).

Conclusions

In acute PE, TAPSE is a robust prognostic marker. The TAPSE/PASP ratio, although associated with mortality, does not provide meaningful incremental value beyond TAPSE and established clinical risk stratification.