[
Correspondence
]
The Prognostic Value of Plasma Heart-Type Fatty Acid-Binding Protein in Acute Pulmonary Embolism To the Editor:
I am writing in reference to the article by Ruan et al1 in this issue of CHEST (see page 1462). The authors conducted an interesting meta-analysis assessing the prognostic value of heart-type fatty acid-binding protein (H-FABP) in acute pulmonary embolism (PE).1 Acute PE is a common and fatal disease. Goldhaber et al2 reported a 90-day mortality rate of about 52% in hemodynamically unstable patients and 14.7% in patients who are hemodynamically stable. Patients who are hemodynamically stable at the time of admission but manifest right ventricular dysfunction (RVD) have poor prognosis when compared with patients without RVD.3 Although thrombolytics are recommended in the treatment of hemodynamically unstable patients, there are, at present, no guidelines for the management of patients who are hemodynamically stable but have RVD. Risk stratification of patients with acute PE is critical for optimal management and enhanced outcomes. H-FABP may support clinicians in the stratification of high-risk patients as well as in the development of recommendations to manage these patients. Ruan et al1 included five prospective studies in the meta-analysis. They compared 30-day mortality and 30-day complicated clinical events (CCEs) in patients with acute PE demonstrating elevated H-FABP levels (above cutoff ) with patients with normal H-FABP levels (below cutoff). Of the five studies used, however, two, by Dellas et al4 and Puls et al,5 had an overlap of 73 patients, which alters the OR for final end points.
TABLE 1
The authors reported a higher OR of 40.78 (95% CI, 11.87-140.01; I2 5 4%) for the 30-day mortality rate and an OR of 32.71 (95% CI, 11.98-82.97; I2 5 21%) for the 30-day CCE. If we exclude the study by Puls et al5 and include only the study by Dellas et al4 (due to higher patient volume), then the OR becomes 31.38 (95% CI, 8.32-118.39; I2 5 23%) for the 30-day mortality and 25.93 (95% CI, 10.72-62.70; I2 5 28%) for the 30-day CCE. Similarly, Ruan et al1 reported prognostic sensitivity of 98% and specificity of 77% for the 30-day mortality. In predicting serious events at 30 days, the prognostic sensitivity and specificity was found to be at 86% and 82%, respectively. Again, excluding the Puls et al5 study results in change of sensitivity and specificity for both 30-day mortality and CCE (Table 1). Anurag Bajaj, MD Scranton, PA AFFILIATIONS: From the Wright Center for Graduate Medical Education, The Commonwealth Medical College. FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Anurag Bajaj, MD, 707 Tall Trees Dr, Scranton, PA 18505; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-1835
References 1. Ruan LB, He L, Zhao S, Zhu P, Li WY. Prognostic value of plasma heart-type fatty acid binding protein in patients with acute pulmonary embolism: a meta-analysis. Chest. 2014;146(6):1462-1467. 2. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet . 1999; 353(9162): 1386-1389. 3. Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure,
] Pooled Summary Results of Prognostic Value of Elevated Heart-Type Fatty Acid-Binding Protein in Acute Pulmonary Embolism
End Points
OR (95% CI)
Sensitivity (95% CI)
Specificity (95% CI)
30-d mortality
31.38 (8.32-118.39)
0.97 (0.85-1)
0.76 (0.71-0.81)
30-d CCE
25.93 (10.72-62.70)
0.83 (0.72-0.91)
0.85 (0.81-0.89)
CCE 5 complicated clinical event.
e236 Correspondence
[
146#6 CHEST DECEMBER 2014
]
and echocardiographic right ventricular dysfunction. Circulation. 2000;101(24):2817-2822. 4. Dellas C, Puls M, Lankeit M, et al. Elevated heart-type fatty acid-binding protein levels on admission predict an adverse outcome in normotensive patients with acute
journal.publications.chestnet.org
pulmonary embolism. J Am Coll Cardiol. 2010;55(19): 2150-2157. 5. Puls M, Dellas C, Lankeit M, et al. Heart-type fatty acid-binding protein permits early risk stratification of pulmonary embolism. Eur Heart J. 2007;28(2):224-229.
e237
Correspondence
]
The Prognostic Value of Plasma Heart-Type Fatty Acid-Binding Protein in Acute Pulmonary Embolism To the Editor:
I am writing in reference to the article by Ruan et al1 in this issue of CHEST (see page 1462). The authors conducted an interesting meta-analysis assessing the prognostic value of heart-type fatty acid-binding protein (H-FABP) in acute pulmonary embolism (PE).1 Acute PE is a common and fatal disease. Goldhaber et al2 reported a 90-day mortality rate of about 52% in hemodynamically unstable patients and 14.7% in patients who are hemodynamically stable. Patients who are hemodynamically stable at the time of admission but manifest right ventricular dysfunction (RVD) have poor prognosis when compared with patients without RVD.3 Although thrombolytics are recommended in the treatment of hemodynamically unstable patients, there are, at present, no guidelines for the management of patients who are hemodynamically stable but have RVD. Risk stratification of patients with acute PE is critical for optimal management and enhanced outcomes. H-FABP may support clinicians in the stratification of high-risk patients as well as in the development of recommendations to manage these patients. Ruan et al1 included five prospective studies in the meta-analysis. They compared 30-day mortality and 30-day complicated clinical events (CCEs) in patients with acute PE demonstrating elevated H-FABP levels (above cutoff ) with patients with normal H-FABP levels (below cutoff). Of the five studies used, however, two, by Dellas et al4 and Puls et al,5 had an overlap of 73 patients, which alters the OR for final end points.
TABLE 1
The authors reported a higher OR of 40.78 (95% CI, 11.87-140.01; I2 5 4%) for the 30-day mortality rate and an OR of 32.71 (95% CI, 11.98-82.97; I2 5 21%) for the 30-day CCE. If we exclude the study by Puls et al5 and include only the study by Dellas et al4 (due to higher patient volume), then the OR becomes 31.38 (95% CI, 8.32-118.39; I2 5 23%) for the 30-day mortality and 25.93 (95% CI, 10.72-62.70; I2 5 28%) for the 30-day CCE. Similarly, Ruan et al1 reported prognostic sensitivity of 98% and specificity of 77% for the 30-day mortality. In predicting serious events at 30 days, the prognostic sensitivity and specificity was found to be at 86% and 82%, respectively. Again, excluding the Puls et al5 study results in change of sensitivity and specificity for both 30-day mortality and CCE (Table 1). Anurag Bajaj, MD Scranton, PA AFFILIATIONS: From the Wright Center for Graduate Medical Education, The Commonwealth Medical College. FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Anurag Bajaj, MD, 707 Tall Trees Dr, Scranton, PA 18505; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-1835
References 1. Ruan LB, He L, Zhao S, Zhu P, Li WY. Prognostic value of plasma heart-type fatty acid binding protein in patients with acute pulmonary embolism: a meta-analysis. Chest. 2014;146(6):1462-1467. 2. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet . 1999; 353(9162): 1386-1389. 3. Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure,
] Pooled Summary Results of Prognostic Value of Elevated Heart-Type Fatty Acid-Binding Protein in Acute Pulmonary Embolism
End Points
OR (95% CI)
Sensitivity (95% CI)
Specificity (95% CI)
30-d mortality
31.38 (8.32-118.39)
0.97 (0.85-1)
0.76 (0.71-0.81)
30-d CCE
25.93 (10.72-62.70)
0.83 (0.72-0.91)
0.85 (0.81-0.89)
CCE 5 complicated clinical event.
e236 Correspondence
[
146#6 CHEST DECEMBER 2014
]
and echocardiographic right ventricular dysfunction. Circulation. 2000;101(24):2817-2822. 4. Dellas C, Puls M, Lankeit M, et al. Elevated heart-type fatty acid-binding protein levels on admission predict an adverse outcome in normotensive patients with acute
journal.publications.chestnet.org
pulmonary embolism. J Am Coll Cardiol. 2010;55(19): 2150-2157. 5. Puls M, Dellas C, Lankeit M, et al. Heart-type fatty acid-binding protein permits early risk stratification of pulmonary embolism. Eur Heart J. 2007;28(2):224-229.
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