O valor da carga embólica na avaliação de disfunção ventricular direita no tromboembolismo pulmonar agudo: quantificando a causa e clarificando as consequências

• Main Authors: Bruno Rodrigues, Hugo Correia, Ângela Figueiredo, Anne Delgado, Davide Moreira, Luís Ferreira dos Santos, Emanuel Correia, João Pipa, Ilídio Beirão, Oliveira Santos
• Format: Article
• Language: English
• Published: Elsevier 2012-11-01
• Series: Revista Portuguesa de Cardiologia
• Online Access: http://www.sciencedirect.com/science/article/pii/S0870255112002016

Resumo: Introdução: A angio-TC pulmonar é o método de escolha para o diagnóstico de tromboembolismo pulmonar (TEP). Estudos têm demonstrado que a gravidade do TEP poderá ser estimada com sistemas de quantificação de carga embólica. Objetivo: Avaliar a correlação entre um score de carga embólica angiográfica (Qanadli score – QS), com os parâmetros de disfunção ventricular direita (DVD), em pacientes com TEP. Métodos: Estudo retrospetivo de 107 pacientes (feminino – 60%), admitidos por TEP (intermédio/elevado risco) numa UCIC (1/1/2007-30/9/2011). Revistas as imagens de angio-TC de 102 pacientes (TCMD-16C) e quantificado o QS. Estabelecido cut-off de 18 pontos por curva ROC. Constituídos 2 grupos (G) (A < 18 versus B ≥ 18 pontos) e comparados os parâmetros clínicos, analíticos, ECG, ecocardiográficos e de angio-TC. Análise estatística com SPSS. Resultados: A idade média foi de 61,4. Nos sintomas de admissão, verificou-se no GB uma prevalência de queixas de cansaço, dor torácica e síncope/lipotimia (p-0,017) bem como score de Geneva, Wells e Shock-index superiores.No ECG, a FC média, percentagem de BCRD, inversão da onda T (V1-V3) e de S1Q3T3 (p-0,034) foram superiores no GB, assim como o ECG score (p-0,009).Analiticamente, o GB apresentou valores de troponina e PDF mais elevados com ClCrMDRD e ratio PO2/fiO2 inferiores. No ecocardiograma, os valores de PSAP foram superiores no GB. Na angio-TC, o GB apresentou diâmetros do VD, ratio VD/VE (p-0,002), veia cava (VC) superior, veia ázigos e seio coronário, superiores. Os diâmetros da artéria pulmonar (AP) e o ratio AP/aorta foram semelhantes. A percentagem de sobrecarga no septo IV e refluxo na VC inferior foram superiores no GB, revelando-se o QS > 18 preditor independente de DVD (VD/VE > 1) (OR:10,85; p < 0,001) (AUC-ROC: 0,79; p < 0,001). A percentagem de tratamento fibrinolítico foi superior no GB (p-0,045), sendo a taxa de mortalidade intra-hospitalar (global-4,9%) idêntica entre grupos. Conclusões: Um QS > 18 pontos revelou-se preditor independente de DVD no TEP, correlacionando-se linearmente com multivariáveis associadas a morbi/mortalidade mais elevada. Abstract: Introduction: Pulmonary angiography by computed tomography (CT) is the method of choice for the detection of acute pulmonary embolism (PE). Studies have shown that the severity of PE can be estimated by clot burden scores. Objective: To evaluate the correlation between an angiographic clot burden score (Qanadli score - QS) and parameters of right ventricular dysfunction (RVD) in patients admitted for PE. Methods: We performed a retrospective study of 107 patients (60% female) admitted to an intensive care unit for PE (intermediate/high risk) between January 1, 2007 and September 30, 2011. Images from 16-slice multidetector CT angiography were reviewed in 102 patients and the QS calculated. Based on a cut-off of 18 points established by ROC curve analysis, two groups were formed (A < 18 points vs. B ≥18 points) and the clinical, laboratory, ECG, echocardiographic and CT angiography parameters were compared. The statistical analysis was performed using SPSS. Results: The overall mean age was 61.4 years. With regard to symptoms at admission, there was a greater prevalence in group B of fatigue, chest pain and syncope (p = 0.017), with higher Geneva and Wells scores and shock index.In terms of ECG parameters, heart rate and percentage of right bundle branch block, T-wave inversion (V1-V3) and S1Q3T3 pattern (p = 0.034) were higher in group B, as was the ECG score (p = 0.009).Laboratory tests revealed that group B had higher troponin and d-dimers, with lower creatinine clearance by the MDRD formula (p = 0.020) and PO2/FiO2 ratio. Echocardiography showed higher pulmonary artery systolic pressure in group B, and CT angiography revealed larger right ventricular (RV) diameters and higher RV/LV ratio (p = 0.002), and greater superior vena cava, azygos vein and coronary sinus diameters in this group. Pulmonary artery (PA) diameter and the PA/aorta ratio were similar. Interventricular septal bowing and reflux of contrast into the inferior vena cava (p = 0.001) were greater in group B, and QS > 18 was an independent predictor of RVD (RV/LV ratio > 1) (OR: 10.85; p < 0.001) (area under the curve on ROC analysis: 0.79; p < 0.001). The percentage of patients receiving fibrinolytic treatment was higher in group B (p = 0.045), and in-hospital mortality was similar in both groups (overall 4.9%). Conclusions: QS >18 points proved to be an independent predictor of RVD in PE, and correlated linearly with variables associated with higher morbidity and mortality. Palavras-chave: Tromboembolismo pulmonar, Score de carga embólica, Disfunção ventricular direita, Keywords: Pulmonary embolism, Clot burden score, Right ventricular dysfunction