Right ventricular dysfunction on echocardiography to predict mortality in acute pulmonary embolism: an individual patient data meta-analysis

Background In patients with acute pulmonary embolism (PE), echocardiography is currently used to detect right ventricular dysfunction (RVD) and to guide risk stratification and treatment decisions. However, the prognostic value of individual RVD parameters in echocardiography, as well as their combinations, remains uncertain. Objectives To assess the association between individual RVD parameters on echocardiography and short-term all-cause death and PE-related death, and to evaluate whether combinations of parameters improve risk stratification. Methods We performed an individual patient data meta-analysis of studies reporting on echocardiographic findings and 30-day mortality in patients with acute PE. Outcomes included short-term all-cause death and PE-related death. Results Overall, 9233 patients were included, with a 7% rate (95% CI, 6%-9%) of short-term all-cause death. Tricuspid annular plane systolic excursion < 16 mm, an estimated pulmonary artery pressure > 30 mm Hg, a right-to-left ventricle diameter ratio > 1, RV hypokinesis, paradoxical septal motion, and dilated RV were associated with short-term all-cause death and PE-related death in univariate analysis. Among 8905 patients with at least 3 RVD parameters assessed, having a single abnormal parameter was not associated with short-term all-cause death (odds ratio [OR], 1.17; 95% CI, 0.92-1.47), whereas having 2 (OR, 1.52; 95% CI, 1.19-1.54) or 3 or more parameters was (OR, 2.33; 95% CI, 1.79-3.03). Among the couple of parameters, a trend toward an increasing association with death was observed for the combination of right-to-left ventricle diameter ratio > 1 and tricuspid annular plane systolic excursion < 16 mm (OR, 2.49; 95% CI, 1.23-5.01) compared with either parameter alone. Conclusion In acute PE patients, RVD parameters from echocardiography are associated with short-term all-cause and PE-related death. The combination of at least 2 RVD parameters identifies PE patients at an increased risk for death.